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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

Injections and costs

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.

Cervical Facet Joint Injections


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 cervical 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 will also help to exclude other problems.

Cervical facet joint injection
The procedure known as cervical facet joint injection is given for pain arising from the small joints in the neck. The pain is usually caused by osteoarthritis and is often known as cervicalgia. 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 and cortisone into your inflamed facet joint. The treatment may be given in the fluoroscopy theatre and 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 nerve supplying the joints are stopped from working using a radio frequency probe in order to reduce pain. This is not a major procedure and referral can be made by your GP. Facet joint injections take less than 1 minute per joint and the results can be dramatic, the response can also help in the diagnosis.

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 are rarely sedated. Being awake is important, because 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.

After the procedure you will need to lie down for a short period before going home. You will be given something to eat and drink if you wish.

Risks
Sometimes, as a result of local anaesthetic reaching the neighbouring nerve roots that supply the arms, there is a feeling of numbness or weakness in one or both arms. This always wears off after a few hours. If this does happen, you must have help getting about at home or, preferably, lie down until normal feeling returns. 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. Some patients experience a few days of 'hot flushing'. However, most have no significant side-effects from these single dose cortisone injections.

After Care and Benefits
The diagnosis is confirmed with increasing pain relief and this 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 start 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. Working with experienced therapists such as Physiotherapists and Osteopaths will help you to regain the strength and mobility lost due to the pain.

You should be able to reduce your drug intake, sleep should be improved and there should be improvement in your posture. You will be followed-up by your therapist in the weeks following the injections.

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.

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.

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.