Pain Medicine Treatment for Common Conditions and Symptoms

Acute Pain

Acute pain is a type of pain that typically lasts less than six weeks, or pain that is directly related to a specific event, such as surgery or an injury. Acute pain is generally of short duration and gradually resolves as the injured tissues heal. Acute pain is usually sharper in comparison to chronic pain.

Examples of acute pain:

• Broken bones
• Cuts and burns
• Dental work pain
• Labor/childbirth pain
• Post-surgical pain

Subacute Pain

Subacute pain is a subset of acute pain. It is pain that has been present for at least six weeks but less than 12 weeks.

Examples include:

• Persistent post-operative pain
• Post-traumatic pain

Chronic Pain

Chronic pain is pain that last for 12 weeks or longer. Our team is trained to treat many different types of chronic pain conditions, including:

• Myofascial pain
• Abdominal pain
• Complex regional pain syndrome
• Headaches/migraines
• Herniated discs
• Joint pain
• Lower back pain
• Neuropathic pain
• Peripheral neuropathies
• Spasticity

Procedures and Treatments

For many patients, the first pain management treatment recommended for neck and back pain may be conservative and include interventions such as physical and/or occupational therapy as well as medication management. When pain persists despite these treatments, other interventional procedures may be contemplated.

Celiac Plexus Block

What is a celiac plexus block?

A celiac plexus block (CPB) is an injection of medicine around the celiac plexus that is performed using fluoroscopic guidance (X-ray). The celiac plexus is a collection of nerves in the abdomen. The most common indication for a CPB is to treat abdominal pain.

The Procedure

Do not eat or drink for at least 8 hours prior to the procedure (see preparation section for other instructions).

When you arrive for the procedure you will change into a hospital gown and an IV will be placed. You will be placed prone on the operating table. Your heart rate, blood pressure and oxygen will be monitored. Your back will be washed with sterile scrub and X-ray images (fluoroscopy) will be taken of your spine.

After numbing of the skin with a local anesthetic, X-ray imaging and small amount of X-ray dye are used for proper location of a small needle near the celiac plexus nerves. A local anesthetic (numbing medication) and possibly a steroid are injected. If destruction of the plexus is sought, alcohol or phenol may be injected. Usually a celiac plexus block takes about thirty minutes to complete.

Differential Nerve Block

What is a Differential Nerve Block?

A differential nerve block is a diagnostic procedure in which the physicians are trying to identify the source of pain. It is not therapeutic. A needle is introduced into the epidural space in the spine and a catheter threaded in that area. Information is obtained from evaluating the response of the pain to the numbing medication.

A differential nerve block is offered to determine the approximate source of a patient’s pain. It is offered if a patient has pain of uncertain cause or that does not respond to standard treatment measures.

Before the Procedure

You will have an evaluation by a staff physician. The procedure will be explained in detail, including the possible complications and side effects. All of your questions will be answered prior to the procedure. For the block to be performed you should have a pain score of at least 4 on a scale of 0 – 10 on the day of the procedure.

The Procedure

An IV (intravenous line) will be placed to provide medication to help you relax if needed and for administering intravenous fluid. Your heart rate, blood pressure and oxygen will be monitored. The procedure will take about 10 – 20 minutes in the procedure suite but the testing with the numbing medication is done in the recovery area and may take up to 3 hours. The catheter may be placed with the patient in the sitting or prone position, with or without X-Ray guidance. An antiseptic solution will be applied to the skin on your back. Local anesthetic will be injected into the skin before the epidural needle is introduced into the epidural space. At this time, a catheter will be placed in the epidural space. Occasionally, a minor electric shock-like sensation may be felt when threading the catheter. You will be offered sedating medication to make you more comfortable during the procedure. In the recovery area, numbing medication will be injected through the epidural catheter. The pain may or may not decrease and you may temporarily get numb and weak in the legs. You will be intermittently assessed for sensation of cold and touch throughout the testing period.

What Can I Expect After the Procedure?

You may experience mild discomfort at the catheter site. These symptoms should be temporary. You can apply ice to affected area on the day of the procedure. If the discomfort persists, apply moist heat to the area.

The effect of the local anesthetics on pain may be variable. The pain may not be relieved at all, relieved partly or completely for a short or long period of time. Expect to resume normal activities or resume work the day after the procedure. This procedure is intended to be diagnostic insofar as we are attempting to identify the source of your pain. THIS IS A TEST, NOT A TREATMENT. Though not therapeutic, the information gathered from the test may guide future care plans.

Discography

Why is Discography Offered?

Discography is offered to determine if the source of a patient’s pain is the intervertebral discs. Intervertebral discs are the cushions between the vertebrae in the spine. Typically, discs do not cause pain. However, patients can have degenerated discs that can be painful. Discography is offered if a patient has low back pain that does not respond to earlier measures and there is evidence of a degenerated disc.

What is Discography?

Discography is a diagnostic procedure in which we are trying to identify the source of low back pain. A needle is placed into the disc and contrast is then injected. Information, such as disc disruption and whether or not the disc is a source of pain is gathered during the procedure.

The Procedure

An intravenous line (IV) will be placed and you will be given antibiotic medications through it. The procedure will take about 30 minutes. You will be lying on your stomach, and antiseptic solution will be applied to the skin on your back. Some pictures will be taken with a fluoroscopy (X-ray) machine. Local anesthetic will be injected into the skin before the needle is introduced into the disc. At this time, disc pressures will be assessed and more pictures will be taken. You will be offered sedating medication to make you more comfortable throughout the procedure.

Epidural Steroid Injection

Why is an Epidural Steroid Injection Offered?

Epidural steroid injections are used to treat conditions that affect the spine from the neck to the lower back. These conditions include herniated discs, protruding discs, degenerated discs, osteoarthritis of the spine, spinal stenosis, and scar tissue or other changes following neck or lower back surgery. These conditions may include numbness, tingling, or pain in the extremities.

What is an Epidural Steroid Injection?

The epidural space is located within the spinal canal one layer superficial to the spinal fluid. Medication such as corticosteroids and /or local anesthetic is injected in the epidural space by the way of a needle or catheter.

An IV (intravenous line) may be placed to provide medication to help you relax and for administering fluid if needed. You will be brought to the operating room and asked to lie on your stomach. Your heart rate, blood pressure and oxygen will be monitored. The area that will be injected will be cleaned using sterile scrub and the skin and underlying tissue will be numbed using a local anesthetic. Your doctor will use X-ray guidance to place the needle in the correct position. Once the needle placement is confirmed with X-ray, a small amount of local anesthetic and steroid will be injected.

Facet Joint Block

Why is a Facet Joint Block Offered?

A facet joint injection is a diagnostic block, meaning it is intended to determine whether the facet joints are the cause of the patient’s back or neck pain.

What is a Facet Joint Block?

A block of the facet joint involves injecting a small amount of anesthetic near the nerves that provide sensation to the facet joint. The facet joints are small joints between each spine level that may cause pain in the neck, mid back, or low back.

Procedure Day

An IV (intravenous line) may be placed to provide medication to help you relax and for administering fluid if needed. You will be brought to the operating room and asked to lie on your stomach or your side depending on the level of the block. Your heart rate, blood pressure and oxygen will be monitored. The area that will be injected will be cleaned using sterile scrub and the skin and underlying tissue will be numbed using a local anesthetic. Your doctor will use X-ray guidance to place the needle in the correct position. Once the needle placement is confirmed with X-ray then a small amount of local anesthetic and possibly steroids will be injected at each level.

Intercostal Nerve Block

What is an Intercostal Nerve Block?

An intercostal nerve block is an injection of local anesthetic (with or without steroid) in the area between the ribs. By numbing the nerves that are located between the ribs, the painful sensation being treated will be blocked.

Why is an Intercostal Nerve Block Performed?

An intercostal nerve block is used to treat pain that is carried by the intercostal nerves. Pain carried by these nerves may be from Shingles (herpes zoster), chest surgery, or from irritation of the intercostal nerves of unknown origin. Intercostal nerve blocks may be for diagnostic and/or therapeutic purposes.

Before the Procedure

You should meet with a pain management physician for a full evaluation. A detailed description of the procedure including risks, benefits, and alternative treatments will be discussed with you. Any questions regarding the procedure should be asked and answered to your satisfaction at this time.

The Day of the Procedure

An IV (intravenous line) will be placed to provide medication to help you relax if needed and for administering fluids. You will be placed prone on your stomach on the operating table. Your heart rate, blood pressure and oxygen will be monitored. Your back will be washed with sterile scrub and X-ray images (fluoroscopy) and/or ultrasound will be taken of your spine.

After numbing of the skin with a local anesthetic, X-ray imaging and small amount of X-ray dye are used for proper location of a small needle near the intercostal nerves. A local anesthetic (numbing medication) and possibly a steroid are injected. The procedure usually takes about 20 minute.

Peripheral Nerve Block

What is a Peripheral Nerve Block?

A peripheral nerve block is an injection of local anesthetic around a particular nerve that lies outside of the spine. The local anesthetic is used to block the pain transmission from that nerve to the brain.

Why is a peripheral nerve block performed?

A peripheral nerve block is performed to identify the particular nerve that is carrying the painful signal. In addition, it may have a therapeutic value as well. Peripheral nerve blocks are performed to treat conditions that include neuralgias and neuritis, osteoarthritis, and to provide anesthesia for surgeries.

The Procedure

*Do not eat or drink for at least 8 hours prior to the procedure (see preparation section for other instructions)

An IV (intravenous line) may be placed to provide medication to help you relax if needed and for administering fluids. The nerve block itself will take approximately 10 minutes to perform. You will be appropriately positioned by the pain medicine staff. The area to be injected will be cleaned with a sterile preparation. The physician will then proceed with the nerve block after injecting some local anesthetic into the skin. A nerve stimulator or ultrasound machine may be used to assist in localizing the nerve to be blocked.

After the Procedure

You must pay strict attention to your pain response to the injection immediately following the procedure.

*Please see After the Procedure section for additional instructions.

Stellate Ganglion Block

What is the Stellate Ganglion Block?

Stellate ganglion is a collection of nerves (sympathetic) that control the blood flow to the upper extremities, elevate the eyelid, widen the pupil of the eye and control sweat production. In certain medical conditions these nerves may carry pain sensation. The stellate ganglion is located at the base of the neck in front of the spine. The stellate ganglion block may be performed to:

1. Reduce pain, burning and sensitivity to the head, neck, arm, and hand on patients with complex regional pain syndrome (reflex sympathetic dystrophy), causalgia, or shingles.
2. Improve blood flow and circulation to the head, neck, arm, and hand in patients with peripheral vascular disease.
3. Decrease hand sweating in patient suffering from excessive hand sweating.

The Procedure

An IV (intravenous line) will be placed to provide medi¬cation to help you relax. You will be placed on your back on the operating table. Your heart rate, blood pressure and oxygen will be monitored. Your neck on the affect¬ed side will be washed with sterile scrub. Fluoroscopic (X-ray) and/or ultrasound guidance is often used. Adhesive temperature probes will be attached to your fingertips to monitor the temperature of your arms.

After numbing of the skin with a local anesthetic, X-ray imaging and small amount of X-ray dye are used for proper placement of a small needle near the ganglion. A local anesthetic (numbing medication) and possibly a steroid are injected. Usually a stellate ganglion nerve block takes five to ten minutes to complete.

What Can I Expect After the Procedure?

Immediately after the procedure you may feel these temporary symptoms:

1. Heaviness and drooping of the eye lid on the same side
2. Stuffy nose
3. Hoarse of voice
4. A “lump” in your throat
5. Hot flush on face, redness of the eye
6. Warmth in the hand and arm on the same side of procedure
7. There may be a decrease in pain, burning and sensitivity on the side arm and hand for a variable period of time.

Before and After Procedure Instructions

These instructions apply to all procedures listed unless otherwise noted.

Preparation for Procedures

• Do not eat solid food for at least 6 hours prior to the procedure. It is alright to have clear liquids up until 2 hours prior to the procedure.*
• Medications for other medical conditions (heart disease, high blood pressure, etc.) can be taken with a small sip of water the morning of the procedure.
• Please let the pain management staff know if you are on any blood thinners medications prior to scheduling the procedure. These medications will need to be stopped prior to the procedure with approval of the prescribing physician.
• Do not take pain medication on the day prior to your procedure. If you are on opiate medications, please ask your pain physician the proper schedule you should take them.
• Diabetic medication will need to be adjusted the day of your procedure. Diabetics who use insulin must modify their insulin dose the day of the procedure because your blood sugar may be affected since you will not have eaten for at least six hours. You can direct any questions or concerns about this to your primary care doctor.
• Bring all your medications with you, so you can continue to take them as usual after the procedure. Do not discontinue any medications without consulting your primary medical doctor.
• You will need to inform the staff of any allergies to medications, X-ray dyes, seafood, shellfish or latex.
• You will need someone to drive you home after the procedure since mild sedation medication may be given by intravenous line. Also, driving or operating any heavy machinery should be avoided until the next day after the procedure.

* For celiac plexus and peripheral nerve blocks, do not eat or drink for at least 8 hours prior to the procedure.

After the Procedure

You will remain in the recovery room for 30 – 60 minutes for observation. You will be offered a snack and the nurse will check your vital signs. Discharge instructions will be given by the nursing staff and you must have an adult drive you home. It is important to record your pain relief and duration of relief immediately after the procedure.

A pain diary is available upon request for you to record your pain levels on a regular basis.

Discharge Instructions

• Avoid driving or operating any heavy machinery until the next day after the procedure.
• You should resume any medications and your regular diet after the procedure.
• You may resume regular daily activity but should avoid strenuous activity the day of the procedure.
• A shower may be taken but baths should be avoided on the day of the procedure.
• If any bandages are over the needle sites, they can be removed the evening after the procedure.

Complications

Complications are rare with the most common being temporary increase pain near the injection site. You can apply ice to affected area on the day of the procedure. If the discomfort persists, apply moist heat to the area. Serious complications are very uncommon but may include bleeding, infection or nerve damage. If pain increases contact your pain doctor. If severe pain, fever, redness or swelling near the injection site, have someone take you to the nearest emergency room to be evaluated for procedure complications or infection.

Expectations

Local anesthetics wear off in several hours but duration of relief varies from individual to individual. If the procedure is used for diagnostic purposes, the results can help guide further management. Expect to resume normal activities or resume work the day after the procedure.