Q&A on Pain Blocks
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.
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
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
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
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
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
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. These
questions (change for error in grammar) 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.