How Injection Therapy can provide nonsurgical relief of symptoms

Injection therapy is both a treatment and a diagnostic tool.

In many cases a 15 minute injection places pain relieving medication directly on the nerve root which can relieve symptoms of radiating pain or numbness into an arm or leg. Instead of a pill that can have side effects on internal organs, a spinal injection puts medication directly by the disc level that is the pain generator.

In this sense, a spinal injection is a treatment.The injection is typically done by a Physical Medicine & Rehabilitation MD or an anesthesiologist trained in interventional spinal injections. The injection can be done in a doctor’s office or an ambulatory surgery center (ASC) in an injection suite with a C-arm for guidance of the needle to the precise location needed.

If the injection at that designated level relieves symptoms, that provides important information to the spine surgeon that the correct herniated disc has been identified. If the injection fails to provide relief, that is also important information for the spine surgeon, because if surgery were to be performed at that level, it wouldn’t relieve symptoms either. In this sense, a spinalinjection is a very important diagnostic tool to identify the correct pain generator.

Ultimately, the goal of a spinal injection is to provide the patient with enough pain relief to bridge from inactivity to physical therapy, where back problems can be better treated with special stretches and exercises. A spinal injection can also enable a person to resume activities like walking and other recreational sports which can also help the back or neck recover.

If you haven’t tried non-surgical treatment options, you are likely pursuing a surgical path perhaps unnecessarily. In the field of spine, specialists use cortisone injections, epidural steroid injections, trigger point injections and nerve blocks to relieve pain in the spine.

Absent emergency symptoms like numbness or weakness in a hand or foot — which DO need to be seen within 48 hours by a spine surgeon to prevent these symptoms to prevent permanent paralysis of the nerves and permanent numbness or weakness — it’s best to try nonsurgical treatment options first to avoid an unnecessary surgery.

Is is possible to be misled by an MRI that shows a disc herniation?

Absolutely. Research studies have shown that about 40% of healthy people over age 40, with no back pain whatsoever, can have disc problems that would show up on an MRI.

Said another way, a herniated disc that appears on an MRI scan does not necessarily have to be the cause of one’s pain symptoms. It could be something else, like a disc problem at another level, an arthritic facet joint, a narrowing of the spinal canal (called stenosis) or other issue.

Injection therapy when done prudently, and not in a repetitious manner, can ensure that if surgery is necessary, the right surgery would be performed on the real problem. If your surgeon did not explore injections, you could be having an unnecessary surgery, or a surgery at the wrong level.

There are two worst-care scenarios that injection therapy is designed to prevent:

• Prevent a person from having a surgery that wasn’t necessary in the first place.’
• Prevent a surgeon from operating on the wrong disc.

In conclusion, if your spine specialist doesn’t at least consider the role of injection therapy in your assessment and treatment, you may be at risk for one of the two worst-case scenarios.

Injection therapy can include any of the following procedures:

Epidural steroid injections

An epidural steroid injection is done to help relieve the symptoms of nerve irritation or inflammation. The irritation or inflammation can occur for a number of reasons including bulging or herniated discs, arthritis and bone spurs that form in the back. Depending upon the nerve, or nerves, involved, patients may develop pain and/or other symptoms in different parts of the body. This could include numbness, tingling, and weakness. Irritation of the nerves in the neck may cause pain in the neck, shoulder and arm. Irritation of the nerves in the upper back may cause complaints in the back, sides, chest or abdomen. In the lower back, irritation or inflammation of the nerves can cause low back pain, buttock or leg pain.

Epidural injections are not always beneficial. About half of the patients getting an epidural steroid injection will have relief of their pain. In some patients the relief may be substantial and long lasting. Some may only get partial relief and others may get no relief at all. If the first injection only gives partial relief, a second and, sometimes, a third injection may be recommended.

Facet Injection

The facet joints are small joints at the back of the spine that act as hinges in our back, connecting all the vertebral bones yet still allowing us to bend and twist with ease. Sometimes, from injury or age, these joints can become irritated or they can develop arthritis and bone spurs, which makes movement painful. Depending on which joints are involved, symptoms of facet joint pain can include neck or shoulder pain, headaches, upper or lower back pain, hip, buttock or leg pain.

To relieve pain symptoms and restore range of motion, the spine physician may inject medication into or around the facet joints. The medicine injected into the facet joints can act like lubricant on a rusty door hinge, helping restore movement. Injections done around the facet joints are done to disable the sensory nerves (known as the Medial Branches) that go to the facet joints. If blocking the Medial Branch nerves is effective, a second procedure known as a Rhizotomy may be done to give a longer lasting benefit. Typically injections are done as a way to bridge the patient to therapy so the therapist can help the patient retain mobility after the effects of the medication wear off.

Trigger Point Injections

Trigger points are painful tissues in and around muscles. Pressure to the painful tissues can cause an aching or sharp pain sensation. Trigger point injections are the administration of a local anesthetic and steroid medication in the muscles where pain is occurring. The injection may relieve spasms of the muscle and may last from weeks to months.

Trigger point injections are performed as an outpatient procedure. The skin at the injection site is sterilely prepped and numbing medication may be used to anesthetize the skin and tissue deep to the skin to make the procedure more comfortable. Patients are monitored for a short time before being discharged home. On the day of the injection, patients are instructed to avoid strenuous activities. Some patients may experience a slight increase in pain for several days as the numbing medication wears off and while waiting for the steroid to work. The day following the injection, patients may return to their normal activities.

Sacro-Iliac Joint Injections

The sacro-iliac joints are two paired joints connecting the lower part of the spine to the pelvis and lower half of the body. The SI joints are very rigid, stable joints due to their bony structure and design as well as their very strong supporting ligaments. Inflammation, irritation and arthritic changes in one or the other joint can occur and cause lower back pain.

Rhizotomy

Rhizotomy is most commonly performed as an outpatient procedure. Sometimes, though not always, an IV is started if medication for relaxation is to be administered. Patients are placed face down on a special x-ray table and the skin at the injection site is sterilely prepped. Numbing medication is then used to anesthetize the skin and tissue deep to the skin to make the procedure more comfortable. A C-arm is used to monitor placement of the probe. Patients are monitored for a short time before being discharged home. On the day of the injection, patients are instructed not to drive and avoid strenuous activities. The day following the injection, patients may return to their normal activities.