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Pain Management

Pain Management Physicians provide comprehensive care for patients suffering from acute and chronic pain.

pain-mgmt

At the Spine and Pain Institute of Orange County, we specialize in successfully diagnosing and treating pain, allowing our patients to regain independence and optimizing their quality of life.

Our Board Certified physicians are experts in Pain Management and Anesthesiology. The Spine and Pain Institute proudly offers the most innovative and effective treatments in use today. From non-invasive options – such as customized physical therapy regimens and medication management – to the newest, minimally invasive techniques, our physicians combine compassion with remarkable expertise.

Our Pain Management Physicians treat pain including but not limited to:

  • Back and neck pain, including pain from compression fractures, herniated discs and unsuccessful surgeries
  • Muscle and joint pain, including arthritis, carpal tunnel and fibromyalgia
  • Work and sports-related injuries
  • Pain associated with cancer
  • Nervous system disorders
  • Traumatic injuries
  • Spasticity management

Finding the Problem

We begin our treatment with a thorough, non-invasive physical examination to determine the origin on pain. This exam involves a complete neurological and musculoskeletal evaluation, as well as surveying the spine, nervous system, extremities and various joints.

Non-invasive Treatments

Many patients benefit from a combination of pain-relieving medications and advanced physical rehabilitation, including customized physical therapy and innovative exercise protocols. Techniques that combine aspects of Eastern medicine with traditional Western approaches can also be helpful.

Minimally-invasive Procedures

CERVICAL EPIDURAL STEROID INJECTION

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

An epidural steroid injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, in the hopes of reducing pain in the neck or 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.

CERVICAL/LUMBOSACRAL SELECTIVE EPIDURAL INJECTION (TRANSFORAMINAL ESI)

The membrane that covers the spinal cord and nerve roots in the spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space before they form the nerves that travel down the arms, along the ribs and into the legs. The nerves leave the spine from small bony openings called foramen. Inflammation of these nerve roots may cause pain in the arms, chest or legs.

These nerve roots may become inflamed and painful due to irritation, such as from a damaged disc or a bony spur. Selective epidural injection (therapeutic nerve root block) places anti-inflammatory medicine over the root and into the epidural space to decrease inflammation of the nerve roots, therefore reducing the pain. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of pain is healing.

CRYOANALGESIA

As part of your treatment at the Spine and Pain Institute of Orange County, your doctor may perform a procedure called Cryoanalgesia. During this treatment, a specialized needle probe is used to “freeze” a nerve, especially those near the skin’s surface, making the nerve unable to transmit pain signals.

DISCOGRAPHY

The discs are soft, cushion-like pads that separate the hard vertebral bones of the spine. A disc may be painful when it bulges, herniates, tears, or degenerates and may cause pain in the neck, mid-to low back, arms, chest wall, abdomen, or legs. Other structures in the spine may also cause similar pain such as the muscles, joints and nerves. Before performing discography, it has usually been determined that these other structures are not the sole source of pain in a patient (through history and physical examination, review of x-rays, CTs/MRIs and/or diagnostic injection procedures such as facet injections, sacroiliac joint injections and/or nerve root blocks). Discography confirms or denies the disc(s) as a source of pain.

This procedure uses the placement of a needle into the discs themselves under x-ray guidance and injection of contrast dye. CT and MRI scans only demonstrate anatomy and cannot absolutely prove a patient’s pain source. In many instances, the discs may be abnormal on MRI or CT scans but not a source of pain. Only discography can tell if the disc(s) themselves are a source of pain. Therefore, discography is done to identify painful disc(s) and help the surgeon plan the correct surgery or to avoid surgery that may not be beneficial. Discography can also be used to determine the appropriate discs for thermocoagulation (a neurosurgical pain relieving technique). Discography is done only if a patient’s pain is significant enough for them to consider surgery or thermocoagulation.

EPIDURAL BLOOD PATCH

An epidural blood patch is performed when a patient seems to be suffering from a spinal headache, which usually resulted from a tear or puncture (intentional or unintentional) of the dura (tissue layer) lining the spinal canal. An intentional hole is made when performing a spinal anesthetic or a spinal tap. It is thought that the leakage of spinal fluid through the hole results in the severe headache. There are many theories as to why or how an epidural blood patch works, but no single mechanism has been identified yet.

FLUOROSCOPIC-GUIDED HIP JOINT INJECTION

Used to diagnosis as well as relieve hip pain, these injections contain anesthetic agents – alone or combined with steroids – to reduce inflammation and provide long term pain relief.

IMPLANTABLE DRUG DELIVERY

A pump implanted in the abdomen releases pain-relieving agents into the spinal cord fluid. Smaller doses of medicine are delivered continuously or at regular intervals, reducing the side effects associated with medications taken by mouth and improving pain control.

INTRADISCAL ELECTROTHERMAL THERAPY

A tiny catheter is inserted into a herniated or torn spinal disc and heated, reducing any tear or disc bulge as well as eliminating pain receptors within the disc.

INTRATHECAL INFUSION PUMP

This modality is usually offered to patients who have been tried on a variety of medical and minimally invasive treatments (e.g. epidurals) without significant success, or when patients experience many side effects with their current medical regimen. Infusion pumps have been used in patients with spastic conditions, cancer-related pain, and in selected patients with non-cancer related chronic pain. Usually patients who are candidates for this modality have been taking higher amounts of medications. However, patients who have good pain relief from their medicines but experience significant side effects (e.g. sedation) are also good candidates.

The pump is a wireless and programmable reservoir that is placed in the abdomen underneath the skin. A catheter from this pump is tunneled under the skin to the back where the medicine is delivered to the fluid that bathes the spinal cord. By doing so, superior pain relief is achieved with a much lower amount of medication. Many of the side effects of medications taken by mouth are no longer an issue since a lot less medicine is required. This pump is usually re-filled every several months.

LUMBAR/CAUDAL EPIDURAL STEROID INJECTION

The membrane that covers the spinal cord and nerve roots in the spine is called the dura membrane. The space surrounding the dura is the epidural space. When the epidural space is in the region of the tailbone, it is called the caudal space. Nerves travel through the epidural/caudal space to the back and into the legs. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contact in some way with the bony structure of the spine.

An epidural steroid injection places anti-inflammatory medicine into the epidural/caudal space to decrease inflammation of the nerve roots, in the hopes of reducing pain in the back or legs. The epidural/caudal 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.

NERVE BLOCKS

Local anesthetics and steroids are injected near specific nerves in the spinal column or peripheral sites, preventing them from relaying pain signals to the brain.

CELIAC PLEXUS, SPLANCHNIC, OR HYPOGASTRIC NERVE BLOCK

As part of your treatment, your doctor will perform one of the above procedures. The purpose of this procedure is to decrease pain and to increase circulation in the area of your pain. This is done by injecting a local anesthetic into an area where a group of nerves that services the internal abdominal or pelvic organs comes together. When circulation is increased, more oxygen and nourishment are brought to the area. The duration of pain relief from this local anesthetic can vary form 1-2 hours to many hours. If your pain is relieved by this procedure, a series of blocks may be desired as an attempt to break the pain cycle.

CERVICAL, THORACIC AND LUMBOSACRAL MEDIAL BRANCH BLOCK

Medial branch nerves are the very small nerve branches that communicate pain caused by the facet joints in the spine. These nerves do not control any muscles or sensation in the arms or legs. They are located along a bony groove in the low back and neck and over a bone in the mid back. If this procedure has been scheduled, there is strong evidence to suspect that the facet joints are the source of your neck/back pain. Therefore, benefit may be obtained from having these medial branch nerves blocked with an anesthetic to see if a more permanent way of blocking these nerves would provide long-term pain relief. Blocking these medial branch nerves temporarily stops the transmission of pain signals from the joints of the spine to the brain.

GANGLION IMPAR BLOCK

The Ganglion Impar Block can be used both as a diagnostic and therapeutic tool in patients suffering from pain in the perineum, distal rectum and anus, vulva, and distal third of the vagina. The technique can be performed with local anesthetic and steroid for nonmalignant pain conditions, such as coccygodynia, or perirectal pain from tumor involvement. Most neurolytic blockades should only be performed for malignant pain conditions, and then only after a diagnostic block is performed. The advantage of the Ganglion Impar Block over other neurolytic procedures for rectal pain is that bowel and bladder function is generally unaffected. However, this should be confirmed first with a local anesthetic block.

INTERCOSTAL NERVE BLOCK

As part of your treatment at the Spine and Pain Institute of Orange County, your doctor may perform a procedure called an intercostal nerve block. The purpose of this procedure is to decrease pain and to increase circulation in the area of your pain. This is done by injecting a local anesthetic along each nerve near the ribs that are involved with your pain. When circulation is increased, more oxygen and nourishment are brought to the area. The duration of pain relief from this local anesthetic can vary from 1-2 hours to many hours. If your pain is relieved by this procedure, a series of blocks may be desired as an attempt to break the pain cycle.

OCCIPITAL NERVE BLOCK

As part of your treatment, your doctor will perform a procedure called an Occiptial nerve block. This is done by injecting a local anesthetic at the back of your scalp. The purpose of this procedure is to relieve pain and to increase circulation in the area of your pain. The duration of pain relief from this local anesthetic can vary from 1-2 hours to many hours. If your pain is relieved by this procedure, a series of blocks may be desired in an attempt to break the pain cycle, or you may receive cryoanalgesia/radiofrequency ablation.

STELLATE GANGLION AND LUMBAR SYMPATHETIC NERVE BLOCK

The sympathetic nerves run on the front surface of the spinal column (not in the spinal canal with the nerves from the central nervous system). The sympathetic nerves are part of the autonomic nervous system that controls involuntary functions. In other words, the autonomic nervous system is responsible for controlling things people do not have to think about or have direct control concerning their function. However, there is a connection between the central and autonomic nervous systems. Sometimes arm or leg pain is caused by a malfunction of the autonomic system secondary to an injury.

A sympathetic nerve block involves injecting medicine around the sympathetic nerves in a lumbar (back) or cervical (neck) area. By doing this, the system is temporarily blocked in hopes of reducing or eliminating pain. If the initial block is successful, then a series of additional blocks may be needed to diminish the pain.

RADIOFREQUENCY ABLATION

A specialized needle is inserted near a nerve and heated, rendering the nerve incapable of transmitting pain.

RADIOFREQUENCY LESIONING

Radiofrequency lesioning is a procedure that uses heat to destroy only the pain fibers to the facet or sacroiliac joints. To the patient, radiofrequency lesioning is very similar to a facet injection or medial branch nerve block. The difference is the administration of heat instead of local anesthetic and steroid.

SACROILIAC JOINT INJECTION

The sacroiliac joints are large joints in the region of the low back and buttocks where the pelvis actually joins with the tailbone. If the joints become painful, they may cause pain in the low back, buttocks, abdomen, groin, or legs. A sacroiliac joint injection serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate pain relief experienced will help confirm or deny the joint as a source of pain. Additionally, steroids will help to reduce any inflammation that may exist within the joint(s).

SPINAL CORD STIMULATOR

Spinal cord stimulation has been successful in pain management for a subgroup of back pain patients that do not respond to minimally invasive procedures such as epidural injections, and are not candidates for spinal surgical interventions. This modality has also been successfully used in patients with Failed Back Surgery Syndrome, Neuropathies/Neuralgias, Peripheral Vascular Disease, Arachnoiditis, Phantom Limb Pain, and Complex Regional Pain Syndrome. After initial evaluation, if you are deemed to be a good candidate, educational material will be given to you by your physician. A psychological evaluation might be necessary prior to the procedure; in some situations, the insurance companies mandate this evaluation.

The procedure is performed in two stages. The first step is the trial and does not involve an incision. During this stage, after an IV antibiotic infusion is started in the preop area, you will be placed in the prone (face down) position. The area of initial injection will be numbed by local anesthetics and, using x-ray guidance, the epidural space will be accessed by a needle. The spinal cord leads will then be advanced into the epidural space to the desired level using fluoroscopic guidance.

TRIGGER POINT INJECTION (TPI)

Chronic muscular pain can result from an injury to a muscle and over time, it can escalate by posturing and non-use of the muscle. This is called myofascial pain syndrome. TPI’s are intra-muscular (IM) injections of local anesthetic (like Novocain), into the muscle sites as a part of myofascial pain syndrome treatment. It is usually used when conservative approaches like, oral medications (anti-inflammatory and muscle relaxants) and rest, are ineffective. TPI’s temporarily numb and relax the muscle sites involved in the pain process. This allows the patient to participate in a more effective physical therapy and stretching of these muscles, and may also increase blood flow to that muscle. Steroids can be used for TPI’s in selected patients.

Clearly, if the first set of TPI’s results in acceptable sustained relief, then there is no need to perform any more injections. If the first set of injections provides no relief, there is no point to repeat any further TPI’s and other causes of pain, or other treatment modalities should be sought. If the first set of trigger point injections results in partial sustained relief, then a series of these injections may provide a greater degree of sustained relief as compared with only one set of injections. Botox® Injection is a good alternative for more prolonged relief, but only if the patient has had positive results with a series of local anesthetics trigger point injections.

VERTEBROPLASTY

Acrylic bone cement is injected through a small needle to stabilize or “cast” compression fractures of the spine, eliminating the source of pain.