Pain Clinic Procedures

 

Pain Clinic Procedures

 


What is an Epidural Steroid Injection?

Epidural Steroid Injection is an injection of long lasting steroid, in the Epidural space – (the area which surrounds the spinal cord and the nerves coming out of it).  

What is the purpose of it?

The steroid injected reduces the inflammation and/or swelling of nerves within the Epidural space.  This may reduce pain, tingling & numbness and other symptoms caused by nerve inflammation / irritation.

How long does the injection take?

The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a mixture of local anaesthetic and steroid medication.

Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues.  Therefore there will be some discomfort involved.  However, the skin and deeper tissues is numbed with a local anaesthetic using a very thin needle prior to inserting the Epidural needle.  It is worth considering that the tissues in the midline have less nerve supply, so it is usual to feel strong pressure rather than pain.

Will I be "put out" for this procedure?

No. This procedure is done under local anaesthesia.

How is the injection performed?

It is done either with the patient sitting on their side, or on their stomach.  The skin in the back is cleaned with antiseptic solution and then the injection is carried out.  After the injection, people are placed on their back or side.

What should I expect after the injection?

Immediately after the injection, it is usual for legs to feel slightly heavy and numb, which is due to the local anaesthetic.  Usually this will last only for a few hours.  It is worth considering that pain will probably return and a "sore back" may be present for a day or two.  This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself.  Relief from pain may be noticeable from the 3rd day.

What should I do after the procedure?

It is strongly advised that people who have this procedure do not drive, insurance may well be voided. 

How long the effect of the medication last?

The immediate effect is usually from the local anaesthetic injected.  This wears off in a few hours.  The cortisone starts working in about 3 to 5 days and its effect can last for several days to a few months.

How many injections do I need to have?

This can vary, some people are offered a course of three injections.  However most people who are referred to the pain clinic have a single injection, which is reviewed about 6 weeks after the initial procedure.  If this injection does not relieve symptoms, another injection may be recommended.  

Can I have more than three injections?

In a six month period, we generally do not perform more than three injections.  This is because the medication injected lasts for about six months.  If three injections have not helped, it is very unlikely that any further benefit would occur after more injections.  Also, giving more injections increases the likelihood of side effects from cortisone.

Will the Epidural Steroid Injection help me?

It is very difficult to predict if the injection will indeed help or not.  Those people who have sciatica respond better to the injections than those who have only back pain.  Similarly, people with a recent onset of pain may respond much better than the ones with a chronic pain condition.

What are the risks and side effects?

Generally speaking, this procedure is safe.  However, with any procedure there are risks, side effects, and possible complications.  The most common side effect is temporary pain, other risks are related to the side effects of cortisone, which include weight gain, increase in blood sugar (mainly in diabetics), water retention, and suppression of natural production of cortisone etc.

Who should not have this injection?

If you are allergic to any of the medications to be injected, if you are on a blood thinning medication, or if you have an active infection going on, you should not have the injection.


What is a nerve block?  

The actual tern "nerve block" is in fact a general term.  It basically means the injection of a local anaesthetic or a neurolytic agent into or near a peripheral nerve, a sympathetic nerve plexus or a local pain-sensitive trigger point.

Who can it help?  

Nerve blocks can help people who suffer from:

How does a nerve block work?
Nerve blocks can be effective in relieving chronic pain.  They do this by preventing the brain from receiving pain 'messages', by blocking or deadening the pain pathways in the nerves themselves.  A local anaesthetic is used to temporarily block the transmission of pain along these pathways.  Two types of sensory pathways are sympathetic nerve plexus and somatosensory nerve.

What are the types of nerve blocks?

Trigger point injection - This is an injection of small amounts of local anaesthetic and steroid in the area of the muscle where pain or tenderness is present.
Facet joint injection - injection of a small amount of local anaesthetic near facet joints (located on the side or your spine, away from the spinal cord).
Stellate ganglion block - injection of local anesthetic around a group of nerves (found in the neck area).
Lumbar sympathetic block - an injection of local anaesthetic around a group of nerves in your lower back (lumbar area).
Intercostal nerve block - an injection of local anaesthetic in the area between the ribs.

What other agents are used in a nerve block?
Besides local anaesthetics, various other drugs and methods are available:

How long does the pain relief last after a nerve block is given?
Dependent on need, n
erve blocks can be administered as a single injection, continuous infusion or indeed as nerve destruction.  Nerve blocks may relieve pain from several hours to several months. 

How effective are nerve blocks?
It is important to remember that no single treatment technique is guaranteed to produce complete pain relief.  Nerve blocks are very effective in providing temporary pain control, but they are only part of a total pain management programme.

What are the side effects?
Although rare, there are people who have allergic reactions to local anaesthetic. 

Steroids are frequently used in nerve blocks and can cause fluid retention, increased appetite, blood pressure and blood sugar fluctuations, and mood swings.

The use of morphine can cause constipation, urinary retention, itching, nausea and vomiting.

The destruction of nervous tissue can cause partial loss of motor or sensory functions.

When should a nerve block not be performed?
A nerve block should not be performed for people who are on anticoagulant therapy with heparin.  This medication can increase the risk of bleeding.  In addition, nerve blocks should not be performed on people who have an active infection around the area of pain or for those who are allergic to local anesthetics or steroids.


Transcutaneous electrical nerve stimulation (TENS)

The aim of TENS is to stimulate the nerves reaching the brain. This makes the body release its own natural pain-killers, the endorphins. TENS has been known to relieve cancer pain, especially if the pain is confined to specific parts of the body. 

Acupuncture

It is thought that acupuncture may work in a similar way to TENS (by stimulating the body to produce endorphins) and may be helpful for some people with chronic pain.


Botulism toxin Type A (Botox®) Injections

On being informed by Dr Searle that a Botulism injection would be helpful, my first thought was 'Oh my God, they're trying to poison me!', when I was then told this was also known as Botox®,  and knowing this was used in cosmetic surgery - my next thought was 'well at least it will get rid of some of my wrinkles!'.

After some research I found:-

 


Cognitive Therapy in Pain Management

Cognitive therapy was developed over thirty years ago by Aaron Beck.  It was originally developed as a treatment methodology for anxiety and depression, and is now employed to treat a variety of psychiatric problems such as anger management and phobias. 

The premise behind cognitive therapy is that our thoughts, beliefs and biases influence our emotions and therefore the intensity of those emotions, and as such it is relevant in the management of pain.  However this does not mean that chronic pain is experienced because of negative thinking, only that it can contribute.

 

It would appear that cognitive/behavioural therapy has a number of objectives within the field of pain management.  The first objective (Jamison 1996) is to help chronic pain sufferers alter the perception of their problem / difficulty from overwhelming to manageable.  This dovetails with the Southern Derbyshire Pain Management Programme aim of encouraging people to take more control and responsibility for their problems and to move from 'patient to person’.

 

Jamison (1996) suggests cognitive therapy is useful for those chronic pain sufferers who view their situation as being catastrophic.  It is suggested that this treatment enables a shift in perception and what was perceived as a hopeless condition can be ‘reframed’ as a difficult yet manageable situation over which the chronic pain sufferer can exercise some control.

 

The second objective is to convince chronic pain sufferers that their treatment is relevant to their problem and that they need to be actively involved both in that treatment and in their rehabilitation.  They need to understand how relaxation, adaptive coping skills and pacing can help decrease levels of chronic pain.  A core principle of cognitive therapy is that chronic pain sufferers should and must alter their self image and perception away from that of passive victim to that of proactive and competent problem solver.  It is noted that when individuals are successful in managing painful episodes, their views subsequently change and they are capable of believing themselves able to overcome any flare-up of pain.

 

The third objective is to encourage chronic pain sufferers to substitute maladaptive thoughts for positive ones.  Persons with chronic pain inevitably are plagued either consciously or unconsciously, by negative thoughts related to their condition.  These negative thoughts have a way of perpetuating pain behaviour and feelings of hopelessness.  Learning how and when to substitute positive thoughts and adaptive management techniques is an important component of cognitive therapy. 

 

 


Mastering Chronic Pain: A Professional's Guide to Behavioral Treatment. by BW Pain Management Center physician Dr. Robert N. Jamison, Ph.D., published by Professional Resource Press, Sarasota, FL, 1996.

 

 

 

 

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