FAQ's (Frequently Asked Questions) about Epidurals, Selective Nerve Root Blocks, and Other Injection Procedures
Of the available treatments, some involve medications or other non-operative therapy. Of surgical treatments, there are traditional open procedures and also less invasive injection type procedures.
Injection procedures, also known as minimally invasive procedures, are preferred by the patients because of the lower risk of complication and the near absence of pain. Most block procedures are of benefit about percent of the time.
Injection procedures include blocks to nerves in the neck or low back. They also include blocks to the peripheral nerves. Injection procedures also include joint blocks for pain. It is possible to inject the small joints in the low back, the sacroiliac joints and most of the other joints in the body. Finally, injection procedures include procedures where the disc is decompressed or where the nerves to the disc are blocked.
The block procedures may only work half of the time, but they also are far less risky than open surgical procedures. It is possible to try the block procedure first, and consider a more major procedure only if the minimally invasive blocks and other shots fail.
The following questions were developed with the help of my patients. If you have more questions, please schedule an appointment and we will be happy to give you answers to all of your questions.
Q. What is the epidural space?
A. The epidural space inside the spinal canal but outside of the "dural membrane" which cover the nerve roots. The epidural space is outside of the membrane called the dura, and surrounds all of the spinal nerve roots. Medicines can be placed in the epidural space where they are absorbed into the nerve roots. This is a common way to treat nerve root pain.
Q. What is an intralaminar epidural injection?
A. An epidural injection is a shot that puts medicine into the epidural space. It is usually done in the middle of the spine. It can be done in the neck or in the back. In the neck they are done more commonly than selective blocks since they are safer. In the low back they are used less frequently but mostly when the pain is widespread.
Q. What is a selective block?
A. A selective block is a shot like an epidural but is injected more precisely. It is not done through the midline like an epidural. Instead, the medicine is place along the nerve root itself. An x-ray machine is used to insure that the medicine is placed exactly.
Q. How do I know that I need an epidural or selective nerve block?
A. If you have neck pain with arm pain, or if you have back pain with leg pain, you probably have a pinched nerve. This is also called a radiculopathy. In the back it is also called sciatica. These blocks will relieve the pain of a pinched nerve, and allow it to heal more quickly. An MRI will show which type of block is best for you.
Q. What is a Facet Joint Injection?
A. The facet joint is a small joint in the neck or back. It is part of the vertebral bone. It can cause pain when arthritic. Injecting steroids can sometimes cure the problem. If this injection does not help the pain, then the facet joint is may not be the problem. If facet blocks are not helpful, one often considers a discogram.
Q. What is a Facet Joint Medial Nerve Branch Block (MBB) Injection?
A. Numbing the nerves that go to the joint, using a local anesthetic like lidocaine, is called a medial branch block (MBB). It is an alternative to a direct facet block. This type of block typically lasts from hours to weeks. Longer periods of relief can be obtained with a median branch rhizotomy (see below).
Q. What is a Facet Joint Medial Branch Rhizotomy?
A. If numbing the nerves that go to the joint is helpful but does not last long enough, one may consider a medial branch rhizotomy. This is done by burning the nerve with an electric current applied through a needle-like probe. A rhizotomy will usually relieve the pain for three to six months or longer.
Q. What is a Sacroiliac Joint (SI) Injection?
A. The sacroiliac joint is the large connection between the sacrum (the bottom of the spine) and the pelvis. This joint may become inflamed or arthritic. Sacroiliac joint pain can be treated with therapy, heat, ice or direct injections .
Q. What is a Peripheral Joint Injection?
A. Peripheral joints are in the arms and legs. The shoulders, elbows, wrists, hips, knees and ankles are all peripheral joints. Treatments for pain may include cortisone injections, arthroscopic surgery and joint replacement surgery. Injections are ordinarily done first to establish the diagnosis. Injections can sometimes cure a painful joint permanently.
Q. What is a Discogram?
A. A discogram is a test to see if a disc is painful. To find the bad disc, the discogram procedure is done by injecting dye into any suspect discs. It can be done in the neck or the low back. If the injection of dye, which stretches the disc, reproduces one’s normal pain, then the damaged disc can be treated. Common treatments for damaged lumbar discs include needle procedures (such as IDET injections), lumbar fusions, and artificial disc replacements. The treatment for damaged cervical discs is almost always a fusion.
Q. What is a Sympathetic Block (Cervical or Lumbar)?
A. The sympathetic nervous system controls autonomous functions such as heart rate, blood pressure and the gastrointestinal tract. When it malfunctions, it can cause uncontrolled chronic pain. The commonest sympathetically mediated pain, or reflex sympathetic dystrophy (RSD or CRPS), can respond to a block of the cervical or lumbar sympathetic nerves. The block may take only a few minutes but may relieve pain for months.
Q. What is a Trigger Point Injection?
A. Trigger points are painful areas of muscle spasm. They can be treated with massage, muscle relaxant medications, meditation, and topical agents. If non-invasive treatments fail, the cycle of spasm causing damage which then causes more spasm and more damage can be broken with an injection. Typically, a local anaesthetic, like lidocaine, with or without a steroid, is injected into the knotted muscle. For the most difficult trigger points, Botox or Myobloc may be employed (see below).
Q. What is a Botox (or Myobloc) Injection?
A. These injections can be used to decrease muscle spasm for many months. Relaxing the muscles may help neck pain, headaches, back pain and some joint dysfunction. Typically they are used after successful trials of short acting trigger point injections with lidocaine. Botox and Myobloc are not fully FDA approved for pain but are well recognized as the standard of care for pain conditions related to muscle spasm.
Q. What is a Nucleoplasty or a Disc Decompression?
A. A bulging disc can push against a nerve. The nerve may be pinched and cause pain in an arm or leg. Decreasing the bulge can correct the problem. A number of manufacturers have developed devices which perform similar functions. The center of the disc can be decompressed with a percutaneous cutter, with a screw like device or with enzymes that dissolve the disc. The laser discectomy is especially elegant in that a camera is included in the device allowing one to deliver a very precise burn and shrink the exact area of disc causing the problem. This procedure can replace open discectomy in some patients.
Q. What is an Internal Disc Electrothermal Treatment (IDET)?
A. A damaged disc can cause back pain. If a discogram is positive, one can consider fusion or an artificial disc. An IDET procedure can provide similar pain control without the need for an open procedure. The procedure is controversial and not currently in favor. It works about half of the time and, when successful, surgery is not needed.
Q. Do the blocks need to be repeated?
A. In most cases the blocks either work or not. About half of the time they work and the pain is relieved. When they work, there is no need for other treatment like surgery. When they work, a second block is not needed. If they do not help at all, there is no reason for a second block. Occasionally, the blocks work but wear off. You can have up to three per year.
Q. Do the blocks just “cover up” the pain?
A. No. The blocks cure the inflammation. The inflammation is the source of the pain. Even though the blocks do not fix a bulging disc or arthritic joint, by healing the inflammation they let the body heal and surgery is avoided.
Q. What happens if the block doesn’t work?
A. The blocks work about half of the time and do not work half of the time. Even if they do not work, they rarely cause harm. When they do not work, your doctor will choose a different treatment. There are many other ways to cure neck and back pain.
Q. How do I schedule a block?
A. To set up a block call us. We will help you figure what kind of block is needed. Blocks are usually done in a surgery center.
Q. What happens before a block?
A. Before the block you will see us for a physical. We will give you all the instructions you will need. Generally you will need to stop aspirin, Motrin, Naprosyn, other anti-inflammatory medications, Heparin, Coumadin and Plavix before the block. If you have other medical problems, you may need to see your internist as well.
Q. What happens after a block?
A. You will need to get to the surgery center an hour or two early. The nurses will take your vital signs, start an IV and have you sign some paperwork. You are then taken to a procedure room where there is an x-ray machine called a fluoroscope. An anesthesiologist will give you some sedation. You are not completely asleep. If you are awake you can help by telling us if you have leg pain. If a needle causes leg pain, we fix the problem by re-positioning the needle. The surgeon will then insert the needles in your neck or back. This takes only a few minutes. Their position will be checked with x-ray and the medicine will be injected. This takes only a minute or two. After the injection, the needles are removed and band-aids are placed. You will go to the recovery room after the shots are done.
Q. What happens after the block?
A. If the block works, your pain will be better almost immediately. You need to have a ride home. At home you will want to rest for a day or so. The block can cause a bruise. Unless told otherwise, wait three or four days before starting anti-coagulants (heparin or Coumadin) and anti-platelet drugs (Plavix for example). Aspirin and non-steroidals can be re-started immediately.
Q. What are the risks of the block?
A. The probability of a problem is low and related principally to the steroid medication which is used. The steroids are can cause immune or problems with the hip joints. These steroids are not the same ones that athletes sometimes abuse. The risks also include that the pain will not go away, that a nerve can be damaged, that you can have weakness or numbness, or that there could be bleeding or infection.
Q. What are the benefits of the block?
A. The benefits of the procedure include relief of pain and eliminating the need for a surgery. The procedure can get you back to work and sports. To decrease the risks, the procedure is done using x-ray guidance.
Q. What do I do if I am using other medications?
A. Tell your doctor about all of your medications. Except for drugs that interfere with clotting, most will not interfere with the block.
Q. What do I do if I still have questions?
A. Please write down all of your questions and bring them to you doctor. This above questions were developed with the help of my patients. We will answer any other questions you many have. We will also likely add them to this web page.