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Specialist Orthopaedic Doctors

Back pain 1

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

Hip Joint Injections

Where patients either have suspected or proven pathology inside the hip joint, intra-articular injection of the hip may well prove beneficial.

What conditions can it be performed for?
Hip injection may provide symptom relief in cases of:

What is injected?
A variety of different substances can be injected into the hip joint. A mixture of local anaesthetic plus steroid is often injected into the joint. The local anaesthetic gives rapid pain relief, although this wears off quite quickly. This makes it more comfortable for the patient and lets your doctor know if all the pain is coming from the hip joint itself. Steroid (also sometime called cortisone) act as a very powerful anti-inflammatory, although it acts just locally, within the joint.

Patients do not get all the same side effects from a steroid injection as they do from having high dose i.v. steroids or prolonged courses of steroid tablets - this is because the steroid acts just locally, within the joint, to reduce inflammation. As well as steroid we are able to inject Hyaluronic Acid (e.g Ostenil, Synvisc or Duralane) into the joint. This acts as a synthetic synovial fluid (which helps lubricate the joint) reducing pain and improving movement. This treatment is especially beneficially in the case of arthritic(wear and tear) changes.

How is it done?
Because the hip joint is quite deep and tight, a long thin needle is used and this is guided into the hip joint under X-ray control. One the needle appears to be in the correct position, a dye is then injected to make sure that the tip of the needle is actually inside the hip joint. The local anaesthetic and steroid can then be injected into the hip joint.

Intra-articular injections into the hip joint are done in our X-ray guided operating theatre with a small amount of local anaesthetic to the skin to make things more comfortable. This ensures the cleanest possible environment, to minimise the potential risks of introducing infection.

Hip injections are normally done as a quick day-case procedure with the patients awake and they are able to go home 30-60 minutes after the procedure. Patients are normally able to fully weight bear pretty much straight away afterwards, although they may potentially need a crutch for assistance afterwards for a short period.

Does it work?
Intra-articular injection into the hip is not going to cure things such as arthritis within the joint. However, it can normally offer good pain relief for a reasonable length of time, although this can range from anywhere between a few weeks up to several months or years depending on what pathology is present and how severe that pathology might actually be.

Autologous Blood Injections

Autologous Blood Injection for the Treatment of Tendinopathy

Tendinosis is thought to be secondary to degeneration of the tendon at its insertion. It is now accepted that there is little inflammation involved but a fibroblastic and neovascularisation (new blood vessel formation) response. Repeated injuries and microtrauma lead to further degeneration. A cycle of degeneration and repair follows with resulting weakening of the tendon with chronic pain and the potential for tendon rupture.

Steroid injections have been used for many years under the assumption that an inflammatory process is involved. They provide symptomatic pain relief but there is no evidence that they promote healing. Any other treatments which involve immobilisation may have a deleterious effect on the long term strength of the tendon rather than helping the condition. Surgical treatments have been described such as "tenotomy" but the associated risks of scarring and bleeding result in this treatment not being frequently used.

Autologous Blood Injection (ABI) has recently been described for the treatment of lateral epicondylosis. Several recent studies have demonstrated its effectiveness for tennis elbow and also for the treatment of other tendonoses such as plantar fasciitis and patella tendinosis. It is assumed that ABI works via Transforming Growth Factor Beta and Basic Fibroblast Growth Factor carried in the blood will acting as mediators to induce a "healing cascade". The mechanism of short term relief following steroid injection or needling is not understood but it may be that trauma to the area of tendinosis with the needle may promote a healing cascade within the tendon.

Neovascularisation has been postulated as a cause for the symptom of pain in tendinosis but clearly the cause of patients symptoms are more complex than can be attributed purely to the new vessel formation, involving inflammation and the stimulation of local pain fibres.

Using ultrasound scanning, it has been seen that following autologous blood injection there is a reduction in tendon thickness and inflammatory changes seen with the tendon. There is also a partial resolution of tendon tears following injection. One of the first studies by Edwards and Calandruccio showed that after an average follow up of 9.5 months there was an improvement in pain and movement in 22 out of 28 patients.

We routinely perform one injection initially and there may occasionally be a requirement of a second injection four weeks later. Most pain relief occurs within the first 4-6 weeks. Patient selection and an accurate diagnosis is critical to the success of the procedure.

From recent studies it would appear that autologous blood injections have a more permanent effect on long-term benefit than that achieved with injection of corticosteroid (cortisone injections). This is probably related to the healing benefits of ABI causing the tendon to return to its pre-injury state rather than simply relying on the anti-inflammatory action of corticosteroid injections.

References:

Sheth U, Simunovic N, Klein G, Fu F, Einhorn TA, Schemitsch E, Ayeni OR, Bhandari M. Efficacy of autologous platelet-rich plasma use for orthopaedic indications: A meta-analysis. J Bone Joint Surg Am 2012 Jan 11.

Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 2011;45:966-971.

Van Ark M, Zwerver J, Van den Akker-Scheek I. Injection treatments for patellar tendinopathy. Br J Sports Med 2011;45:1068-1076

Edwards SG, Calandruccio JH... Autologous blood injections for refractory lateral epicondylitis. J Hand Surg 2003;28A:272-278

Iwasaki M, Nakahara H, Nakata K, Nakase T, Kimura T, Ono K. Regulation of proliferation and osteochondrogenic differentiation of periosteum-derived cells by transforming growth factor-β and basic fibroblast growth factor. J Bone Joint Surg 1995;77A:543-554.

Connell D, Burke F, Coombes P, McNealy S, Freeman D, Pryde D, Hoy G. Sonographic examination of lateral epicondylitis. AJR 2001;176:777-782

Kraushaar BS, Nirschl RP. Tendinosis of the elbow (Tennis Elbow). Clinical features and findings of histological, immunohistochemical and electron microscopy studies. J Bone Joint Surg 1999;81-A:269-278.

Lian O, Holken KJ, Engebrestson L, Bahr R. Relationship between symptoms of jumper's knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Scit Sports 1996;6:291-296

Khan KM, Cook, JK. Overuse tendon injuries. Clinical Sports Medicine, McGraw-Hill 2nd edition January 2001.

Trigger Points

Trigger points are often treated successfully with a course of local injections containing a small dose of corticosteroid combined with local anaesthetic, unless the spinal joints nearby are the source of the problem. If this is the case, the joints themselves have to be treated first and the muscles should then relax of their own accord. Local injections are often most helpful if they are combined with stretching exercises to help muscles relax. If the pain comes from sprained ligaments, you might find that the injury is slow to heal. A few people need a local injection of steroid with some local anaesthetic added.

The doctor will identify your strained ligament with his fingers and inject a drop at one end, shift the needle slightly and inject another drop, working this way until the ligament has been injected along its entire length and breadth.

You may feel some soreness or aching for 24 to 28 hours after a steroid injection. Your doctor will tell you to rest the joint by refraining from excessive lifting, carrying and bending. You will also be advised not to sit in one position for long periods. After about ten days, your doctor will see you again so that he can assess your progress.

The reason why you need to rest is because the collagen (protein fibre) that provides tension in the ligaments is affected for the first 10 to 14 days after a steroid injection, which makes the tissues a bit weaker. After this the ligament collagen returns to normal. A small amount of steroid will probably be absorbed into your blood, but not enough to cause any side-effects.

Injection Treatments

The treatment of your back pain or sports injury may involve an injection. These injections are undertaken in our purpose built fluoroscopic theatre suites by one of our Musculoskeletal, Sports Injury or Pain Management Specialists who have undertaken many years of training and may be members of:

At the Blackberry Clinic we are able to inject your low, mid and upper back as well as your neck and perform nerve blocks. To help arthritic pain or injuries from sports you may be suitable for injections to your hip, knee, shoulder as well as smaller joints in your hands or feet. Injections therapies have also been shown to help tendon injury and inflammation such as Tennis Elbow, Golfer's Elbow and Plantar Fasciitis.

At the Blackberry Clinic we pride ourselves on being at the forefront of treatments and are able to offer treatments involving the injection of Hyaluronic Acid, Platelet Rich Plasma and Autologous Blood. The site contains more information about all of these as well as more generalised information regarding what to expect, possible side effects and the benefits and risks of injection therapies. If there is anything further you would like to know please Contact Us or ask your therapist or doctor at the Blackberry Clinic.

Below is a summary of the costs charged at the Blackberry Clinic:

 

Consultation, follow up, treatment and procedure costs

Initial consultations

  1.   Doctor         £165 (includes ultrasound scan or x-ray during appointment)
  2.   Physio          £45
  3.   Osteopath    £45
  4.   Chirpractor   £45

Follow up appointments

  1.   Doctor          £130 (includes ultrasound scan or x-ray during appointment)                                                 
  2.   Physio           £45
  3.   Osteopath     £45
  4.   Chiropractor  £45

Treatment prices inclusive of consultation:

Prolotherapy Back/knee                                       £250 per treatment/£400 for 2 areas, (usually course of 3 treatments required)

PRP (Platelet Rich Plasma) +/- imaging               £250/350 per treatment per area (1-3 treatments required)

Non-Spinal injections (no imaging)                      £250        

Non-Spinal Injections (with imaging)                   £350    (ie. with ultrasound or x-ray)      

Spinal injections (+ other advanced injections)   £500    (ie. with ultrasound or x-ray)                                                                                                             

Hyaluronic Acid Joint injection 1 joint                 £450       per injection   (course of 3 required)

Hyaluronic Acid Joint injection 2 joints                £550      per injection   (course of 3 required) 

Radiofrequency Denervation                                 £700

 

Spinal Injections

What Treatments Are Available? What is a Spinal Injection?
Your doctor has suggested that you have a spinal injection to help reduce pain and improve function. This procedure can help relieve pain by reducing inflammation (swelling and irritation). An injection can also help your doctor to identify the source of your pain, by numbing certain areas of your back. Some injections can even strengthen ligaments in the back. The type of injection you receive is based on your specific symptoms and the results of your physical examination.

Anatomy of Your Spine

  • Vertebrae are block shaped bones that form your spinal column.
  • Discs are spongy shock absorbers between each of the block shaped vertebrae. A herniated disc or a disc with 'wear and tear' may cause inflammation and pain.
  • Facet joints are small joints in the back of the spine that guide the bending motions of each vertebra. These joints can become irritated or inflamed and cause pain.
  • Spinal nerves are branches from the spinal cord exiting the spinal column. They transmit signals that control the movement of your muscles and provide sensation in your arms and legs. These nerves can also become irritated or inflamed and cause pain.
  • The epidural space is the space around the sheath (dura) covering the spinal nerves. Placing anti-inflammatory medicine in the epidural space can help to reduce spinal nerve inflammation.
  • Sacroiliac joints (SI joints) are found between your lower spine (sacrum) and pelvic bone (ilium). Inflammation in these joints can cause low back, buttock and other pain.

Preparing for Your Injection
A spinal injection is an outpatient or daycase procedure. Before your injection, you will be asked questions about your general health. You will also be given instructions on how to prepare for the procedure:

  • Provide a list of the medicines you take, including blood thinners, aspirin, anti-inflammatory medicines such as ibuprofen, and over-the-counter and herbal medicines and supplements. You may need to stop taking some of these before the procedure - please ask your healthcare provider. Generally, you should continue to take medicines necessary to your health such as blood pressure or thyroid medicines. It is safe to take products containing paracetamol.
  • Provide a list of any allergies you may have to medicines, latex or contrast dye.
  • It is a good idea to arrive at your appointment with some of your usual pain present. This will make it easier to tell if the injection blocked your pain. This is why spinal injections are sometimes called 'blocks'.
  • You may be asked to have someone available to drive you home after the procedure.
  • It may be necessary not to eat or drink for 4 hours before the procedure - check with the doctor. If you are taking medicine for diabetes, tell your doctor. Your medicine may have to be adjusted both before and after the injection.
  • Bring any X-ray films and CT or MRI scans with you on the day of the procedure.
  • If your health changes - if there is the possibility that you have a cold, flu or other illness - it is important that you tell the doctor or nurse. He or she may want to reschedule the procedure.

If you need to cancel your procedure, please notify your doctor as soon as you know.

Checking In
You should arrive a little early to fill out any necessary paperwork before the procedure. Have your insurance documents with you. For your benefit and safety, current medical information may be requested again. It is important to alert your doctor if you are experiencing any new or recent medical problems. Your doctor may decide to give you a brief physical exam.

Risks and Complications
All medical interventions have risks and benefits. Spinal injections have certain risks and complications that may include:

  • Spinal headache (rare)
  • Bleeding (rare)
  • Infection (rare)
  • Allergy to the medicines (rare)

These are treated quickly and rarely result in long term problems.

During the Procedure

  • The procedure is usually brief, but your position during the procedure is important to make the injection go smoothly, with the least discomfort to you. You may have monitoring devices attached to you during the procedure to check your heart rate and blood pressure.
  • Your skin will be cleaned with a sterilising solution and a sterile drape will be placed over your skin.
  • Conscious sedation (use of a calming drug while you are awake) may be used through an intravenous line if your doctor feels it is appropriate.
  • Local anaesthetic (lidocaine) is usually given near the injection site to numb the skin. This typically feels like a pin prick.
  • Fluoroscopy (X-ray imaging) is often used for precise placement of the injection. Contrast dye may be injected to confirm the correct placement of the needle.
  • A local anaesthetic for numbing (eg, lidocaine, bupivicaine) and/or a steroid (i.e cortisone to reduce inflammation) is injected.
  • A small bandage may be placed at the injection site.
  • After some injections, you may spend time in a recovery area.
  • You may be monitored to make sure you are doing well and your vital signs may be checked.
  • You may be asked to fill out paperwork before leaving.
  • You will normally be advised to have someone drive you home.
  • You may put ice packs on the injection site for 10-20 minutes at a time if there is soreness. Avoid burning your skin with the ice by placing a towel between the ice and your skin.
  • You may take a shower but avoid baths, pools or whirlpools for 24-48 hours following the procedure.
  • You may be asked to relax on the day of injection, but usually can resume normal daily activities the day after the injection.
  • You can usually start or resume your individualised exercise programme or physical therapy programme within 1 week of your injection.
  • Side effects, which may occur but will go away within a few days, include:
    - Briefly increased pain
    - Headaches
    - Trouble sleeping
    - Facial flushing
    - Menstrual disturbance
  • It takes a few days, even a week or longer, for the steroid medicine to reduce inflammation and pain.
  • Your doctor may want to follow-up with you in 1-3 weeks.

If you had sedation, you should not drive for 24 hours after the procedure.