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Specialist Orthopaedic Doctors

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Back Pain Injections

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Fluoroscopically Guided Digital X-Ray Injections

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Spinal Manipulation

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Exercise & Rehabilitation Programmes for the Young...

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...and the Not So Young

Facet Joint Radiofrequency Denervation

Otherwise known as: Radiofrequency Facet Joint Neurolysis or Radiofrequency Facet Joint Nerve Ablation

Denervation means an 'interruption of the pain-carrying nerves', in this case the ones supplying the facet joints in your back. It is done using radiofrequency (RF) lesioning. This is a safe, proven means of interrupting pain signals. RF current is used to heat up a small volume of nerve tissue, thereby interrupting pain signals from that specific area. Clinical data shows that RF lesioning can effectively provide lasting pain relief.

Treatments and Side Effects
RF lesioning is performed by the specialist in an operating room setting. Both local anaesthesia and a mild sedative may be used to reduce any discomfort during the procedure. You will need to be awake and alert during both the sensory and motor stimulation process to aid in properly pinpointing the placement of the lesioning electrode.

During the radiofrequency denervation procedure you will be lying on your stomach. After the local anaesthesia has been administered, the doctor will insert a small needle into the general area where you are experiencing pain. Under X-ray guidance, he will then guide the needle to the target area. A microelectrode is then inserted through the needle to begin the stimulation process. During this process, you will be asked by your doctor if you are able to feel a tingling sensation. The object of the stimulation process is to help your doctor to ensure the electrode is in the optimal area for treatment, thus producing the most relief.

Once the needle and electrode placement is verified, treatment is ready to begin. A small RF current will travel through the electrode into the surrounding tissue, causing the tissue to heat and eliminate the pain pathways. You should alert your doctor if at any time during the procedure you experience any discomfort.

After the procedure you may experience some soft tissue discomfort at the needle placement sites. Like other soft tissue wounds, the discomfort will subside over several days. Food and liquid consumption can usually be resumed soon after the procedure.

RF treatment usually blocks pain signals for a prolonged period of time. However, the human body may regenerate pain pathways over time. It is not unusual that the procedure may need to be repeated. More than 80% of patients experience 10 months or more of significant pain relief.

RF treatment will not limit your day-to-day activities. You should be able to resume your normal activities, including work, as soon as you feel able. However, any pre-existing physical restrictions you had prior to the procedure may still remain. You will be in the Clinic for approximately 1—2 hours in total. An appointment will be made for a follow-up.

Nerve Root Injections/Blocks

A trapped, inflamed nerve can cause pain in your arm or leg without any neckache or backache (brachialgia or sciatica). An injection of local anaesthetic and steroid around the nerve root will anaesthetise the nerve and reduce any inflammation. One or two small nerves convey pain messages to and from the facet joints and the dural sheath, and these can also be blocked and anaesthetised by this technique.

These nerve root block injections are performed by quite a small number of musculoskeletal or orthopaedic physicians who have a special interest in relieving pain from spinal disorders. These specialist doctors are extremely useful for chronic sufferers and if your own doctor cannot help, he might still be able to refer you to someone with the expertise to give these injections.

At the flagship Blackberry Clinic in Milton Keynes, this type of injection can be given in our fluoroscopy theatre which is adjacent to our Outpatient Clinic. There is no need for a general anaesthetic. To numb the area you will be asked to lie on your front on a couch while the physician injects a small amount of local anaesthetic. Subsequently, the nerve root block can be performed under X-ray guidance. The treatment is not painful and takes about 10 minutes. The nerve block injection itself may only take 30 seconds.

If the relevant nerve root has been located successfully, the anaesthetic mixed with steroid will provide significant pain relief. Prolonged or even permanent relief may be obtained. Once again, the results are variable and it is difficult for doctors to predict how well a particular individual will respond. There are few side effects, if any, from this injection. If the needle has pierced the dura, there will be no further symptoms or problems after the initial day or two's headache and dizziness. The only tiny risk from this injection is that very occasionally the doctor may pierce the dural membrane. Although it will not be very painful, you will have to lie flat for 24 hours if this happens in order to avoid a headache or dizziness caused by any excessive leak of cerebrospinal fluid. This is by no means as serious as it may sound. After two days the doctor will attempt the correct placement of the needle once again. Because of this small risk, it is advisable to take someone with you to drive you home in case you need to spend a day in bed, though if all goes as it should, you will be able to walk or drive yourself.

FAQs about Cortisone/Steroid Injections


What is Cortisone?

Cortisone is a powerful anti-inflammatory medicine that reduces inflammation around the nerve tissue and can break into the cycle of entrapment and swelling. This reduces pain, numbness and weakness.

Is there a limit to the number of injections that you can have?
In any particular place in the body, there is a natural limit of three injections in a six week period. Further injections are allowed in other places and at other times, especially if they are effective. Your specialist will guide you.

What complications may occur?

Hot flushes
- for 1-2 days (1 in 20).

Allergic reaction
- to any injection may occur in 1 in 7,000 cases. This may just be a rash or a life-threatening reaction. These will usually occur immediately and will be treated immediately. Most reactions are treated and cause no permanent harm.

Bleeding
- Epidural Haematoma and resulting nerve damage is a very rare (1 in 7,000) complication after a bleed around the nerves. This usually requires surgery to remedy.

Infection
- Very rarely (1 in 7,000) an Epidural Abscess or infection in other tissues can occur. You should watch for signs of fever, redness, swelling and increasing pain. This can be treated with antibiotics or even surgery.

Lumbar Facet Blocks


Diagnostic medial branch block

The procedure known as a medial branch block is a diagnostic injection given to numb one or two joints to see if the pain reduces significantly for a few hours. If this is the case, then a lumbar facet joint injection may be given on the next visit into the joint or joints identified as producing pain. This diagnostic injection is the best single way of identifying a painful joint. X-rays, MRI scans and clinical examination also help to exclude other problems.

Lumbar facet joint injection
The procedure known as lumbar facet joint injection is given for pain arising from the small joints in the back. The pain is usually caused by osteoarthritis and is often known as lumbago. It is different from the sharp pain of sciatica, which travels down the leg.

Facet Joint Injections
Most backache related to facet joints can be treated successfully with a combination of exercise and improved posture. If your symptoms are very severe or difficult to treat, you may need an injection. In this case, your doctor will inject a mixture of local anaesthetic into your inflamed facet joint. The treatment may be given in the doctor's fluoroscopy theatre and it may be slightly painful.

Results
These injections can be very successful but occasionally provide relief for only a few months. If you are suffering from severe osteoarthritis you may find that some of the newer techniques are beneficial. These include facet joint denervation by which the nerves supplying the joints are frozen or deadened with a radio frequency probe in order to reduce pain. This is not a major operation and referral can be made for this by your GP. Facet joint injections take less than 15 seconds per joint and the results can be dramatic and can help in the diagnosis. If the injections provide only partial or temporary relief, it may be necessary to use Prolotherapy - a dextrose/glucose injection which strengthens the supporting ligaments of the lumbar spine.

Treatments and Side Effects
The doctor will have discussed alternative treatments with you first. He may have talked about Manipulation, Acupuncture, TENS or alternative medications/injections but these may not be suitable for everybody. You will be asked if you agree to the treatment. If you do, you will be asked to lie on your stomach under an X-ray machine. Identified joints may then be injected. The X-rays used are a much smaller dose than you would receive if you had a normal back X-ray.

Local anaesthetic is used, so it is not an excessively painful procedure and patients rarely need sedation. Being awake is important as we need to know which joint is tender when the needle comes into contact with it. For short-term relief and diagnostic purposes, only anaesthetic need be injected. Adding a long-acting cortisone, however, can sometimes result in several months of pain relief. This is not the same as taking steroids for long periods, as in rheumatoid arthritis.

Risks
You might not feel any benefit for the first day or two and some people feel worse temporarily for a few days. This may be due to bruising or soreness near to the injection site. It is recommended that you do not drive yourself home, although you may feel perfectly able to do so. Some people do experience a few days of 'facial flushing'. However, most people have no significant side-effects from these single dose cortisone injections.

After Care and Benefits
The diagnosis is confirmed and the pain relief should allow you to gradually increase your activities. It is important that you do not immediately take up unaccustomed exercise until your muscles have had time to acclimatise to it. Ideally, you should resume exercising in a mild fashion, taking two walks a day but limiting the distance and time to the level that you know you can easily manage. You should be able to reduce your drug intake, sleep should be improved and there should be improvement in your posture.

Epidural Injection For Back Pain

Research studies have shown the benefit of epidural steroid injections for spinal disc lesions causing Sciatica. The purpose of the injection is to carry the medicine to the inner part of the back where the more serious types of strain, affecting the discs or joints, cause pressure or irritation of the nerves. The structures are bathed by the anti-inflammatory steroid to reduce swelling and pain.

The solution contains a mixture of saline and corticosteroid (not Depomedrone). It may be injected by the caudal route (just above the tail-bone) or between the spinous processes. The injection can be performed safely as an out patient or day case procedure without the need for overnight stay or general anaesthetic. In the majority of cases it is not a painful procedure, although you may experience some feeling of pressure as the volume of fluid is pushed in, or reproduction of your sciatic pain temporarily. After the procedure, you will be expected to rest for a while (20 minutes or longer) before going home.

With the 'caudal epidural injection' you may experience some temporary light headedness after the procedure. If a different type of epidural ('interlaminar epidural') is used using local anaesthetic, there may be some weakness or unsteadiness after the injection. For this reason, you should not drive a vehicle or operate machinery until the next day. The benefit may appear almost immediately or build up gradually over a week or 10 days. It is extremely unlikely that you will experience any other significant side effects. Due to the corticosteroid component, some women may develop a facial flush the next day which lasts 12-24 hours and, less commonly, some disruption of the menstrual cycle for one or two cycles. Other possible complications are similar to those of any injection and very rare, namely infection or allergic reaction which can occur in approximately 1 in 7,000 cases and can be dealt with promptly. There is no satisfactory evidence of any long term complication from epidural steroids.

Using X-ray guidance, the physician will identify the base of the sacrum before administering the injection. He may have an nurse or assistant who helps during the procedure. A non-ionic contrast dye may be injected so that the physician can identify correct placement of the epidural injection. The steroid/saline solution is then injected slowly over a period of about 10 minutes. The needle enters the spinal canal through the base of the sacrum, and the saline mixed with steroid penetrates up the canal to reach the level of the third lumbar vertebra.

If the pain relief is short-lived but significant, the epidural injection may be repeated to give a longer-lasting effect, so do not be too disappointed if the pain eventually returns after the first injection. Your pain may be the same, or worse in some cases than before the procedure. This will last for 24-48 hours and is part of the normal process.

The procedure will be fully explained to you before your appointment. If you have any further questions, please ask - or visit our FAQ section. Please report any known allergies (drugs, elastoplast etc) to the doctor prior to the procedure. Most people leave the Clinic within one hour of their appointment. You will need a competent adult to drive you home and if you live alone, please ensure that you have a competent adult to take care of you until the following day. After any procedure, it is advisable to go home and rest (preferably lying down) for the remainder of the day and preferably the next day too. The doctor will guide you as to the exact amount of rest needed. Sitting and any long car journeys are to be avoided.

If in the rare event you do experience any untoward reaction in the following 24 hours, such as shortness of breath, dizziness or severe headache, please contact the Clinic immediately, or if it is out of hours, contact your GP or go directly to the Accident and Emergency Department of your local hospital.