Spine Pain Management

A myelogram requires introduction of radiographic contrast media (dye) into the sac (dura) surrounding the spinal cord and nerves. This outlines each descending nerve fiber to allow better visualization. The patient lies on their stomach during the test. After the skin area has been numbed, the dye is injected into the spinal sac followed by X-rays, CT, or MRI scans. After the images are processed, a radiologist interprets the results and sends a report to the referring physician.

Following the myelogram, the patient is taken to a recovery area where they rest lying down with their head elevated for several hours. Once at home, quiet nonstrenuous activities are recommended for 24 hours to allow the puncture site to heal. Plenty of fluids (e.g. water, juice) should be consumed to clear the dye from the body.

Important Considerations
Certain medical conditions, drugs, or allergies should be discussed with the referring physician prior to the myelogram. Some of these topics are listed below.

1. Metallic components such as a pacemaker, aneurysm clip, or other metal implants prohibit the patient from an MRI scan.
2. Allergies to contrast dye should be reported. Adverse reactions include hives, swelling, and difficulty breathing. Foreknowledge of an allergy can often be controlled by pre-medicating.
3. Epilepsy or seizure disorder, and if medication is taken to control episodes.
4. Angina or kidney disorders.
5. Diabetic patients who control their disease with medication need to discuss this with their physician. Certain drugs may need to be discontinued for 48 hours prior to the test.
6. Blood thinners may need to be discontinued prior to the test.
7. Difficulty lying flat on the stomach or inability to remain still.

Patient Preparation

1. The patient will need someone to drive them home following the test. This should be prearranged in advance of the scheduled test day.
2. Bring prior relevant X-rays, CT or MRI scans for the radiologist’s review.
3. Do not eat anything after midnight the night before the myelogram. Some patients experience side effects such as nausea and vomiting. Clear liquids are acceptable.
4. Take scheduled medication with clear liquid, unless the referring physician has instructed otherwise (e.g. diabetics).

Possible Side Effects
Most patients do not experience any side effects from a myelogram. However, common risks include headache, extremity aches or discomfort, nausea, vomiting, or dizziness, which usually disappear within 24 hours.

Sometimes, persistent side effects (e.g. headache) require a blood patch. This is a safe procedure performed by an anesthesiologist sealing the small hole created by the injection of dye into the sac (dura). The anesthesiologist draws some blood from a vein in the arm and injects the blood into the sac (dura, epidural space)— this seals the tiny hole and prevents additional cerebrospinal fluid (CSF) from leaking.

If symptoms persist after 48 hours, contact the referring physician and/or medical facility.

General Information:
Epidural Steroid Injections (ESIs) are a common method of treating inflammation associated with low back or related leg pain. In both of these conditions, the spinal nerves become inflamed due to narrowing of the passages where the nerves travel as they pass down or out of the spine. Injection into the epidural space places medication along nerves as they exit the spinal canal.

Why Get an Epidural Steroid Injection?
Narrowing of the spinal passages can occur from a variety of causes, including disc herniations, bone spurs, thickening of the ligaments in the spine, joint cysts, or even abnormal alignment of the vertebrae (‘slipped vertebrae’, also known as spondylolisthesis). The epidural space is a fat filled ‘sleeve’ that surrounds the spinal sac and provides cushioning for the nerves and spinal cord. Steroids (‘cortisone’) placed into the epidural space have a very potent anti-inflammatory action that can decrease pain and allow patients to improve function. Although steroids do not change the underlying condition, they can break the cycle of pain and inflammation and allow the body to compensate for the condition. In this way, the injections can provide benefits that outlast the effects of the steroid itself.

How Are Epidural Steroid Injections Performed?
There are three common methods for delivering steroids into the epidural space: the interlaminar, caudal, and transforaminal approaches. All three approaches entail placing a thin needle into position using fluoroscopic (x-ray) guidance. Prior to the injection of steroid, contrast dye is used to confirm that the medication is traveling into the desired area. Often, local anesthetic is added along with the steroid to provide temporary pain relief.

An interlaminar ESI, often referred to as an ‘epidural injection’, involves placing the needle into the back of the epidural space and delivering the steroid over a wider area.

Similarly, the caudal approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space. With both approaches, the steroid will often spread over several
spinal segments and cover both sides of the spinal canal.

With a transforaminal ESI, the needle is placed alongside the nerve as it exits the spine and medication is placed into the ‘nerve sleeve’. The medication then travels up the sleeve and into the epidural space from the side. This allows for a more concentrated delivery of steroid into one affected area (usually one segment and one side). A transforaminal ESI can provide diagnostic benefit, in addition to improved pain and function.

All three procedures are performed on an outpatient basis and you can usually return to your pre-injection level of activities the following day. Some patients request mild sedation for the procedure, but many patients undergo the injection using only local anesthetic at the skin.

What Happens After the Injection?
The steroid will usually begin working within 1-3 days, but in some cases it can take up to a week to feel the benefits. Although uncommon, some patients will experience an increase in their usual pain for several days following the procedure. The steroids are generally very well tolerated, however, some patients may experience side effects, including a ‘steroid flush’ (flushing of the face and chest that can last several days and can be accompanied by a feeling of warmth or even a low grade increase in temperature), anxiety, trouble sleeping, changes in menstrual cycle, or temporary water retention. These side effects are usually mild and will often resolve within a few days. If you are diabetic, have an allergy to contrast dyes, or have other serious medical conditions, you should discuss these with your doctor prior to the injection.

Epidural steroid injections have been performed for many decades and are generally considered as a very safe and effective treatment for back or leg pain. Serious complications are rare, but could include allergic reaction, bleeding, infection, nerve damage, or paralysis. When performed by an experienced physician using fluoroscopic guidance, the risk of experiencing a serious complication is minimized. Overall, ESIs are usually very well-tolerated.

Although not everyone obtains pain relief with ESIs, often the injections can provide you with improvement in pain and function that last several months or longer. If you get significant benefit, the injections can be safely repeated periodically to maintain the improvements. Injections are also commonly coupled with other treatments (medications, physical therapy, etc) in an attempt to either maximize the benefit or prolong the effects. You should consult with your doctor to develop a comprehensive care plan.

The injection can be done in the lumbar spine and is specific to one side of body.

If the patient’s pain is relieved by the injection for the duration of the local anesthetic, the spinal surgeon can have increased confidence that surgery at this level will help relieve the patient’s pain.

The procedure is done in a radiology room and usually takes 15-30 minutes. Local anesthetic is used from the skin down to the spine. A longer-lasting local anesthetic is used for the actual injection along the nerve which can last up to 6 or more hours.

The patient does not need to be NPO (without food or water) prior to the test. The scheduling nurse will inquire if the patient is taking blood thinning medication and ask about the patient’s history of allergies. A driver should come with the patient as there is expected numbness in the arm or leg for several hours. Usually, this does not affect walking though patients are advised to be careful about going up or down steps until the local anesthetic has worn off.

A diagnostic injection should be done on a day in which the patient is having actual pain symptoms so that a definite determination can be made as to whether the patient’s pain has been modified or relieved by the injection. The injection is not 100% specific as there may be multiple levels contributing to the symptoms or the injection may slightly affect an adjacent level.

The procedure may also be done with a therapeutic injection of steroid medication to further reduce nerve irritation.

Zygoapophyseal Joint Blocks (Facet Joints)
Each spinal vertebra rests on and transmits the supported weight of the body through three points to the adjacent vertebra. These three points are the intervertebral disc in front and two zygoapophyseal or facet joints towards the back of the spine.

The facet joints are prone to arthritis. Inflamation in the joint may irritate and inflame adjacent nerves causing back and sometimes radicular pain. Local anesthetic can be injected into the joint or along the nerves that supply the joint (Medial Branch Block).

If the patient’s pain is relieved by the injections, the procedure helps determine that the pain is arising from the joints rather than from another source of back pain.

Medial branch blocks involve multiple injections as nerves from above and below supply the joint.

This procedure requires approximately 30 minutes per level. Patients need not be NPO (without food or water) and may drive themselves home soon after the procedure.

These blocks are often combined with an injection of steroid medication into the joint for a longer, more therapeutic effect.

Orthopedic Hardware Block
Following fusion procedures or other implantation of orthopedic hardware, pain can sometimes develop from the hardware. To determine if this is the source of pain, an injection of local anesthetic can be made along the hardware insertion points. Pain relief over the duration of the local anesthetic is a good indicator that the hardware is a source of pain.

The procedure is done in a special fluoroscopic room that allows multiple angles of visualization of the hardware. There is no special patient preparation and the injection usually takes less than 20 minutes.

Spondylolysis Block
A spondylolysis defect is a crack in a portion of the neural arch that surrounds the spinal canal. This defect lies between the vertebral body and the two zygoapophyseal joints which are the three weight bearing points of each vertebra. The defects are thought to be caused from previous injury. If they occur on both sides of the neural arch, they can allow a slippage (spondylolithesis) of one vertebra forward upon another.

A precise injection of local anesthetic can be made into the defect to determine if it is a source of pain. This is usually done with fluoroscopic or computed tomography guidance. The procedure requires no special preparation and usually takes less than 30 minutes.

Pseudoarthrosis Block
The lowest lumbar or first sacral vertebra may develop a variation called a transitional vertebra. In this variant, a portion of the vertebra above is enlarged and curves down to meet the vertebra below. If these do not fuse together, they can form a false joint or pseudoarthrosis. If the two parts rub against each other during spinal motion, a painful arthritis can develop. This false joint can also be injected with local anesthetic to determine how much it contributes to the patient’s pain symptoms. The injection is done using either fluoroscopic or computed tomographic guidance and takes about 30 minutes. There is no special patient preparation.

Injection of local anesthetic into the joint can help determine if it is a major cause of the patient’s symptoms. Research shows that sacroiliac pain is very often confused with back pain from the spine.

When is the Sacroiliac Joint Steroid Injection required?
The sacroiliac (SI) joint Injection is performed to relieve pain caused by arthritis in the sacroiliac joint, where the spine and pelvic bone meet.

In general, a sacroiliac joint block is performed to achieve one or both of the below goals:

• Diagnostic: Diagnostic blocks are administered with the purpose of trying and establishing the exact structural abnormality causing the symptoms. This is also known as finding the ‘pain generator’.
• Therapeutic: In this type of an injection, corticosteroids are injected to reduce the inflammation at the source of the problem that is causing the symptoms. An SI joint injection can be repeated up to 3-5 times per year.

What is the procedure?
The procedure is aimed at placing the medication into the sacroiliac joint, either on the left or right side. Normally these injections are done with computed tomography (CT) guidance, as this best insures that the injected medicine is delivered well into the joint.

1. An IV line may be started so that adequate relaxation medicine can be given, if needed.
2. The patient lies on their stomach and the skin over the posterior back is well cleaned.
3. The physician numbs a small area of skin with an anesthetic (a numbing medicine). The patient may feel a sting that will last for a few seconds.
4. Physician uses computed tomography (CT) to direct a very small needle into the joint.
5. A small mixture of anesthetic and steroid “cortisone” is then slowly injected. The needle is removed and a small band-aid is used to cover the entry site. The procedure takes 20 to 30 minutes for one joint and requires no special patient preparation.

The injection should be followed by other treatments (medication, physical therapy, etc.) to provide mobilization and range of motion exercises.

• Diagnostic function: 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. If complete pain relief is achieved while the hip joint is numb it means this joint is likely to be the source of pain.
• Pain relief function: Along with the numbing medication, steroid “cortisone” is also injected into these joints to reduce inflammation, which can often provide long-term pain relief.

Hip joint injection procedure
Fluoroscopy (x-ray) is commonly used in hip joint injections for guidance in properly targeting and placing the needle, and for avoiding large blood vessels and nerves.

On the day of the injection, patients are advised to avoid driving and doing any strenuous activities.

The hip joint injection procedure includes the following steps:

1. An IV line may be started so that adequate relaxation medicine can be given, if needed.
2. The patient lies on their back on an x-ray table and the skin over the hip is well cleaned.
3. The physician numbs a small area of skin with an anesthetic (a numbing medicine). The patient may feel a sting that will last for a few seconds.
4. The physician uses x-ray guidance (fluoroscopy) to direct a very small needle into the joint. Several drops of contrast dye are then injected to confirm that the medicine only reaches the joint.
5. A small mixture of anesthetic and steroid “cortisone” is then slowly injected into the joint.

The injection itself only takes a few minutes, but the overall procedure will usually take between thirty and sixty minutes. After the hip joint injection procedure, the patient typically remains resting on the table for a few minutes, and then is asked to move the area of usual discomfort to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the joint that was injected is the main source of the patient’s pain. On occasion, the patient may feel numb or experience a slightly weak or odd feeling in the leg for a few hours after the injection.

Pain relief after a hip joint injection
Patients may notice a slight increase in pain lasting for a few days as the numbing medicine wears off and the cortisone is just starting to take effect. If the area is uncomfortable in the first two to three days after the injection, applying ice or a cold pack to the general area of the injection site will typically provide pain relief and appear more beneficial than applying heat.

If the hip joint that was treated is the source of the pain, the patient may begin to notice pain relief starting two to five days after the injection. If no improvement occurs within ten days after the injection, then the patient is unlikely to gain any pain relief from the injection and further diagnostic tests may be needed to accurately diagnose the patient’s pain.

Patients may continue to take their regular medications after the procedure, with the exception of limiting pain medicine within the first four to six hours after the injection, so that the diagnostic information obtained is accurate. Patients may be referred for physical therapy or manual therapy after the injection while the numbing medicine is effective and/or over the next several weeks while the cortisone is working.

On the day after the procedure, patients may return to their regular activities. When the pain has improved, it is advisable to start regular exercise and activities in moderation. Even if the pain relief is significant, it is still important to increase activities gradually over one to two weeks to avoid recurrence of pain. Injections are also commonly coupled with other treatments (medications, physical therapy, etc) in an attempt to either maximize the benefit or prolong the effects. You should consult with your doctor to develop a comprehensive care plan.

Overview: This injection procedure is performed to relieve trochanteric bursitis. Most patients with trochanteric bursitis will frequently complain of lateral hip pain that radiates down the leg, mimicking sciatica. Often the patient is unable to sleep on the affected hip. The steroid medication can reduce the swelling and inflammation in the trochanteric bursa.

Indications: Trochanteric bursitis, the primary indication for therapeutic injection at this site, usually is associated with chronic pressure or trauma to the area. Leg-length abnormalities, obesity, rheumatoid arthritis, and osteoarthritis are associated factors in many patients. Friction from a tight iliotibial band, typically seen in runners, also can cause this problem. Diagnosis is confirmed by palpation of tenderness, and sometimes swelling, in the region of the bursa.

The greater trochanter bursa injection procedure includes the following steps:

1. An IV line may be started so that adequate relaxation medicine can begiven, if needed.
2. The patient lies on their back and the skin over the lateral hip is well cleaned.
3. The physician numbs a small area of skin with an anesthetic (a numbing medicine). The patient may feel a sting that will last for a few seconds.
4. The physician uses x-ray guidance (fluoroscopy) to direct a very small needle into the bursa. Several drops of contrast dye are then injected to confirm that the medicine only reaches the joint.
5. A small mixture of anesthetic and steroid “cortisone” is then slowly injected into the bursa. The needle is removed and a small band-aid is used to cover the entry site.

The injection itself only takes a few minutes, but the overall procedure will usually take between thirty and sixty minutes. After the injection procedure, the patient typically remains resting on the table for a few minutes, and then is asked to move the area of usual discomfort to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the joint that was injected is the main source of the patient’s pain.

Iliopsoas Tendinitis / Bursitis

The pain is difficult for patients to localize and challenging for clinicians to reproduce. In fact, the average time from the onset of symptoms to diagnosis is 31 to 42 months. It is common for many other diagnoses to be entertained and treated with no improvement. Physical examination will reveal pain on deep palpation over the femoral triangle, where the musculotendinous junction of the iliopsoas can be palpated as a doughy diffuse area of tenderness at the midpoint of the inguinal ligament.

Pain may also be produced when the affected hip is extended or when the supine patient raises his or her heels off the table at about 15 degrees. In the latter position, the only active hip flexor is the iliopsoas.

Procedure:
The steroid injection can be done either with fluoroscopy (x-ray) or ultrasound. Imaging is used for guidance in properly targeting and placing the needle, and for avoiding large blood vessels and nerves.

1. Place patient supine. Palpate the femoral vessel. Identify the iliopsoas tendon/ landmarks with ultrasound or fluoroscopy. Document the appearance of the tendon, including the presence of bursal fluid.
2. The skin site overlying the tendon is cleaned and draped in a sterile fashion. Sterile prep for ultrasound probe.
3. The physician numbs a small area of skin with an anesthetic (a numbing medicine). The patient may feel a sting that will last for a few seconds.
4. The physician uses x-ray guidance (fluoroscopy) or ultrasound to direct a very small needle into the bursa. Several drops of contrast dye are then injected to confirm that the medicine only reaches the bursa.
5. A mixture of anesthetic and steroid “cortisone” is then slowly injected.
6. Needle is removed and sterile dressing is applied.

Unlike local anesthetics, the onset of action of steroid medication is variable and can range from immediate to several days or even a week. For diagnostic injections, this can mean a gap between the relief of the local anesthetic and the onset of improvement from the longer acting steroids.

More than one injection of the steroid may be necessary in a given area. Long-term use of steroids does carry risk factors. These can range from increased bone loss and possible bone fracture or loss of blood supply to suppression of the adrenal glands and interference with blood sugar control in diabetics. Usually, the short-term benefits far outweigh the long-term risks. Patients undergoing surgery should remind their physicians that they have been taking steroid treatments. Most physicians try to limit the number of steroid injections to around three in a six-month period.

Potential risks of steroid injections
As with any procedure, there is a risk of complications. Possible side effects from a steroid injection include:

• Allergic reactions to the medications used
• Infection (occurs in less than 1 per 15,000 injections)
• Mental status changes (anxiety, hyperactivity and possible pyschosis, especially in patients with history of bipolar disorder)
• Post-injection flare (joint swelling and pain several hours after the corticosteroid injection)
• Depigmentation (a whitening of the skin)
• Local fat atrophy (thinning of the skin)
• Rupture of a tendon located in the path of the injection
• Blurred vision, frequent urination, increased thirst
• Change in blood sugar levels, especially in diabetic patient

If fever, chills, increased pain, weakness or loss of bowel/bladder function occurs, you should immediately seek medical attention.

All of these procedures/injections can easily be done by interventional radiology. You can ask for a referral from your doctor, call Advanced Medical Imaging at 402-484-6677 or call the radiology department of any hospital and ask for interventional radiology.