Injections

What’s great about epidural steroid injections

If you’re at the point where you need an epidural steroid injection, you’ve likely tried other treatments to ease your pain, including medication or physical therapy. These injections work by delivering steroid anti-inflammatory medications along with local anesthetic to stressed nerves.

Epidural treatment is especially helpful for the types of pain that plague many people: a variety of back problems, from sciatica (which causes lower back pain) and degenerative disc disease pain to spinal stenosis, herniated discs, and radiculitis. It’s also effective at relieving neck pain, and even leg pain.

In addition to the much-needed pain relief you feel quickly after the shot, epidural steroid injections can help you avoid surgery.

Types of epidural steroid injections and who they help

The three most frequently used types of epidural treatments treat pain in different locations of the body:

1. Transforaminal epidural steroid injection

This epidural steroid injection is administered by inserting the needle between your spine and spinal cord, or the vicinity of where your spinal nerve exits your spine. When a nerve root in this area becomes inflamed and irritated, you feel pain that starts in your back and extends down the leg.

The transforaminal injection is particularly helpful in treating sciatica and a host of other back problems.

2. Caudal epidural steroid injection

We give you this shot if your pain is focused at the base of your spine. We insert the needle below the lumbar spine, or the lower back. These injections can help with back problems such as herniated discs and leg pain from sciatica.

3. Interlaminar epidural steroid injection

These shots can be given anywhere on the spine and are particularly effective when treating back, leg, neck, and arm pain.

After thoroughly evaluating your medical history and chronicling your pain, we recommend the type of epidural steroid shot he thinks matches your needs best. If the thought of an epidural steroid injection of any sort makes you uncomfortable because you simply don’t like needles, rest assured the process is brief and painless.

When you come to Advanced Spine and Pain for an epidural steroid shot, we make you as comfortable as possible. First, we give you a local anesthetic at your injection site so you feel nothing during the procedure. Getting the injection takes only 10-15 minutes on average, but if your condition and pain are more severe, you may get more than one.

After your injection, we observe you for about half-an-hour to ensure that you don’t have any reaction, and then you’re on your way. If you have any tenderness, an ice pack does the trick.

It’s also important to know that it’s normal to experience a bit more pain directly after getting the injection and a few days afterwards. You also might feel immediate relief, though improvement often continues for the next two to four days. Best of all, the relief your injection provides keeps you pain-free for a number of months.

Epidural steroid injections can be used in concert with other pain-relief approaches, or they might be your primary treatment. Our patients’ feedback is consistently positive about epidural steroid injections, and most of the time, these shots are more than worth it, especially if other approaches have failed.

Call the Advanced Spine and Pain office that’s most convenient for you to schedule an epidural steroid injection consultation today, or reach out to us through our website.

Radiofrequency Ablation for Pain Management

Radiofrequency ablation (RFA) uses heat to destroy tissue. For pain management, radio waves are sent through a precisely placed needle to heat an area of the nerve. This prevents pain signals from being sent back to your brain. RFA is considered for long-term pain conditions, especially of the neck, lower back or arthritic joints that haven’t been successfully treated with other methods.

What is radiofrequency ablation (RFA)?

Radiofrequency ablation (RFA), also called radiofrequency neurotomy, uses radio waves to create a current that heats a small area of nerve tissue. The heat destroys that area of the nerve, stopping it from sending pain signals to your brain. RFA can provide lasting relief for people with chronic pain, especially in the lower back, neck and arthritic joints.

Why is radiofrequency ablation (RFA) done?

The goals of radiofrequency ablation are to:

• Stop or reduce pain.
• Improve function.
• Reduce the number of pain medications taken.
• Avoid or delay surgery.

What conditions can be treated with radiofrequency ablation?

Radiofrequency ablation is used to treat:

• Chronic pain caused by conditions including arthritis of the spine (spondylosis) and sacroiliac (SI) joint pain.
• Pain in your neck, back and knee.
• Cancer pain.
• Facial pain caused by trigeminal neuralgia.
• Peripheral nerve pain.
• Heart rhythm problems.
• Tumors (to kill cells).

How does radiofrequency ablation work?

Radiofrequency ablation uses heat produced from radio waves to target diseased tissue. When radiofrequency is applied to nerve tissue, it damages nerves, which prevents or stops the pain signal from reaching the brain and results in pain relief.

During a radiofrequency ablation procedure, a small hollow needle is inserted into the targeted nerve that is causing pain. An electrode is inserted into the top of the needle, which sends the radio waves through the needle to the targeted nerve. The heat causes a lesion that prevents the nerve from sending pain signals to your brain. Nearby healthy nerves are not damaged during the procedure.

Pain management within your spine

Radiofrequency ablation is often used to manage pain originating from joints (such as your knee) and oftentimes related to pain from your spine, especially your neck and lower back (lumbar area of your spine).

Within your spine, nerves branch off from your spinal cord and travel to the facet joints and sacroiliac joints.

Facet joints are pairs of small joints between the vertebrae in your spine. These joints give your spine flexibility and allow movement of your back, such as twisting and bending. Two small nerves, called medial branch nerves, are connected to the facet joints and send a signal to your brain that there is pain coming from these joints.

Sacroiliac joints are found near the bottom of your spine, right above your tailbone. Lateral branch nerves that are connected to these joints send pain signals from the spine to your brain.

Using radiofrequency ablation to treat the targeted medial branch nerve in the facet joints or the lateral branch nerve in the sacroiliac joints decreases pain signals from reaching your brain.

Who is a candidate for radiofrequency ablation (RFA)?

Radiofrequency ablation (RFA) may be right for you if have:

• Pain relief following a nerve block injection. This tells your provider that that particular nerve is the source of your pain and is an appropriate target for RFA.
• Chronic pain that does not respond to other treatment, such as pain medication and physical therapy.

You may not be a candidate for radiofrequency ablation if you:

• Are pregnant.
• Have an infection.
• Have a bleeding problem.

PROCEDURE DETAILS

What happens before a radiofrequency ablation (RFA) procedure?

Your healthcare provider will review your medical and medication history and ask you questions about your pain. If you take aspirin or other blood-thinning medications, you may need to stop taking them for a few days before the procedure.

Your provider will examine you and order X-rays or other imaging tests that are typically ordered to see your anatomy, determine the level of arthritis or other spine injury and rule out any other causes.

Your provider will perform a test, called a diagnostic block, to confirm the source and level of your pain, which can then predict the potential level of your pain relief. The block consists of an injection of a local anesthetic near the area of pain. If the diagnostic block doesn’t provide significant relief, you may not benefit from RFA. If you have a favorable response to the diagnostic block, your provider may recommend RFA as a treatment to ease your pain.

What happens during a radiofrequency ablation procedure?

First, you’ll lie on your stomach on a special X-ray table. Your healthcare provider will use monitors to watch your condition during the procedure. You’ll remain aware so you can answer your provider’s questions during the procedure. Medications can be given during the procedure to relax you but this is optional.

Your doctor will use a local anesthetic to numb the area of your skin where a needle will be inserted. Then:

• A thin needle is inserted into the area where you feel pain.
• Needle placement is guided by a special kind of real-time continuous X-ray called fluoroscopy.
• Once the needle has reached the intended site, your doctor will do a test to confirm it’s in the proper position. The test consists of inserting a microelectrode through the hollow needle. Your doctor will ask if you feel a tingling sensation (or discomfort or a muscle twitch). This means the right location has been found for treatment.
• A local anesthetic is injected through the needle to numb the target area.
• A radiofrequency current is sent through the needle to heat the identified portion of the nerve.
• The current destroys that area of the nerve, stopping it from sending pain signals to your brain.
• More than one nerve can be treated during the procedure (if needed).

How long is the radiofrequency ablation procedure?

Radiofrequency ablation takes from 15 minutes to two hours to complete, depending on the treatment location and number of treatments performed.

What happens after a radiofrequency ablation procedure?

After your radiofrequency ablation procedure:

• You’ll go home shortly after your procedure. Someone must drive you home.
• Rest when you get home. Don’t drive or do anything strenuous for 24 hours after the procedure. After a day or two, you can return to your normal activities, including bathing or showering.
• You may still feel soreness, pain or muscle spasms at the treatment site for a few days. Your healthcare provider may have prescribed pain medication for the soreness and pain. You can also apply an ice pack to the injection site, off and on for 20 minutes a few times during the first day of your recovery at home.

Your provider may have also recommended physical therapy to regain strength and flexibility. You’ll also have a follow-up appointment to check on your progress and to have any questions you may have answered.

RISKS / BENEFITS

What are the advantages of radiofrequency ablation?

Advantages of radiofrequency ablation include:

• Pain relief.
• No surgery.
• Little to no recovery time.
• Decreased need for pain medications.
• Improved function.
• Return to regular activities after a day or two of rest.

What are the side effects and risks of radiofrequency ablation (RFA)?

During the procedure, you may experience some pain or burning sensation at the site, similar to what you experienced before the procedure. The pain may last for a week or two after the procedure. Applying an ice pack at the site, 20 minutes off and on, may help relieve the pain.

You may feel some temporary numbness where the needle entered your skin.

The risk of complications from RFA is very low. On occasion, permanent nerve damage or pain can occur. In some people, their original pain may get worse. Other complications, including infection and bleeding at the needle insertion site, are uncommon.

RECOVERY AND OUTLOOK

How effective is radiofrequency ablation?

Most people have some pain relief after radiofrequency ablation, but the amount varies by cause of pain and location. Pain relief can be immediate in some people, occur within 10 days in other people or may take up to three weeks in others.

Pain relief can last from six months to 12 months. For some people, the relief lasts a few years. Others may have only limited pain relief.

The treated nerve can regrow. If this happens, it usually happens about six to 12 months after the procedure. Radiofrequency ablation can be repeated if needed.

Talk with your healthcare provider about the success rate of your procedure and the length your pain relief may last. Your provider will give you their best projection based on the specific cause, location and severity of your pain.

WHEN TO CALL THE DOCTOR

When should I call my healthcare provider?

Call your healthcare provider if you:

• Have severe pain, redness or swelling at the needle insertion site.
• Have increased weakness or numbness in an arm or leg.

FREQUENTLY ASKED QUESTIONS

Is radiofrequency ablation considered surgery?

Radiofrequency ablation is not considered a surgery. It’s considered a minimally invasive procedure. This means the procedure is performed using methods that access your body with the least amount of damage or disruption to your skin and tissues. In general, minimally invasive treatment methods lower the risk of infection and other complications, reduce the length of hospital stay, lessen the amount of pain experienced and shorten recovery time.

A note from Cleveland Clinic

Radiofrequency ablation (RFA) uses heat to destroy tissue. When used for pain management, heat is used to target specific nerves that cause you pain. Heating the nerve stops or reduces pain signals from reaching your brain. RFA is considered for long-time pain conditions involving your spine after other methods, such as pain medication and physical therapy have not been successful. RFA is helpful for many people who decide to have the procedure. Talk with your provider to see if RFA is right for you.

What is a spinal cord stimulator and how does it work?

Spinal cord stimulators consist of thin wires (the electrodes) and a small, pacemaker-like battery pack (the generator). The electrodes are placed between the spinal cord and the vertebrae (the epidural space), and the generator is placed under the skin, usually near the buttocks or abdomen. Spinal cord stimulators allow patients to send the electrical impulses using a remote control when they feel pain. Both the remote control and its antenna are outside the body.

Experts still don’t fully understand the mechanisms behind spinal cord stimulation, but they now know that it may target multiple muscle groups directly from the spine and even alter how the brain senses pain.

Traditional spinal cord stimulators replace the sensation of pain with light tingling, called paresthesia. For patients who find these paresthesiae uncomfortable, newer devices offer “sub-perception” stimulation that cannot be felt.

Many of the latest devices are placed by physicians with highly specialized training in interventional pain management under X-ray and/or ultrasound guidance.

What is spinal cord stimulation used for?

Spinal cord stimulation is used most often after nonsurgical pain treatment options have failed to provide sufficient relief. Spinal cord stimulators may be used to treat or manage different types of chronic pain, including:

• Back pain, especially back pain that continues even after surgery (failed back surgery syndrome)
• Post-surgical pain
• Arachnoiditis (painful inflammation of the arachnoid, a thin membrane that covers the brain and spinal cord)
• Heart pain (angina) untreatable by other means
• Injuries to the spinal cord
• Nerve-related pain (such as severe diabetic neuropathy and cancer-related neuropathy from radiation, surgery or chemotherapy)
• Peripheral vascular disease
• Complex regional pain syndrome
• Pain after an amputation
• Visceral abdominal pain and perineal pain

Spinal cord stimulation can improve overall quality of life and sleep, and reduce the need for pain medicines. It is typically used along with other pain management treatments, including medications, exercise, physical therapy and relaxation methods.

Who should get a spinal cord stimulator?

As with all treatments, your doctor will want to make sure spinal cord stimulation is right for you ⁠— and that it is likely to provide significant relief from your chronic pain. To make this recommendation, your pain specialist will likely order imaging tests and psychological screening. Some insurance companies require psychological screening to ensure disorders like depression or anxiety aren’t worsening your pain.

Each patient is different, but generally, people who benefit the most from spinal cord stimulation are those who:

• Have not experienced sufficient pain relief with medications, less-invasive therapies or prior surgeries
• Do not have psychiatric disorders that would decrease the effectiveness of the procedure

Spinal Cord Stimulator Types

Spinal cord stimulators come in three main types:

1. Conventional implantable pulse generator (IPG) is a battery-operated spinal code stimulator. A battery is placed in the spine during an operation. When it runs out, the battery must be replaced with another surgery. This device can be a good choice for people with pain in just one body part because it has a lower electrical output.
2. Rechargeable IPG works similarly to the conventional device, with the difference that the battery can be recharged without another surgery. Because the energy source is rechargeable, these stimulators can put out more electricity. This may be a better choice for people with pain in the lower back or in one or both legs, as the electrical signal can reach further.
3. Radiofrequency stimulator uses a battery that’s outside the body. This stimulator is rarely used today because of newer designs and better technology. It has rechargeable batteries, and like the rechargeable IPGs, it may be better for people with pain in the lower back and legs because of the device’s power.

Your surgeon will explain how to operate the device and adjust the intensity of the electrical signal, which all three types of stimulators support. Different body positions may require different stimulator settings, such as one setting that works better for sitting and another for walking). To help you easily access the most used settings, most devices allow doctors to save two or three preset programs. Some newer devices feature several waveforms for electricity delivery, including high frequency, burst and high-density stimulation.

Spinal Cord Stimulator Surgery

Spinal cord stimulators require two procedures to test and implant the device: the trial and the implantation.

Spinal Cord Stimulator Trial

The first step is a trial period. Your surgeon will implant a temporary device for you to test out. Guided by a specific type of X-ray called fluoroscopy, your surgeon will carefully insert the electrodes in the epidural space of the spine. The location of your pain affects where these electrodes will be placed along the spine. Your surgeon may ask for your feedback during the procedure to best position the electrodes.

This trial procedure typically requires only one incision in your lower back to place the electrodes. The generator/battery will be outside the body, typically on a belt, you’ll wear around your waist.

For about a week, you will evaluate how well the device reduces your pain. The trial is considered a success if you experience a 50% or greater reduction in pain level.

If unsuccessful, the wires can easily be removed in the clinic without damage to the spinal cord or nerves. If successful, surgery is scheduled to permanently implant the device.

Spinal Cord Stimulator Implantation

During the permanent implantation procedure, the generator is placed underneath the skin and the trial electrodes are replaced with sterile electrodes. Unlike the trial electrodes, these will be anchored by sutures to minimize movement.

The implantation can take about 1-2 hours and is typically performed as an outpatient procedure.

After the local anesthesia has been administered, your surgeon will make one incision (typically along your lower abdomen or buttocks) to hold the generator and another incision (along your spine) to insert the permanent electrodes. The incisions are about the length of a driver’s license. As in the trial procedure, fluoroscopy is used to determine where the electrodes are placed.

Once the electrodes and generator are connected and running, your surgeon will close the incisions.

Your surgeon may provide sedation to keep you comfortable and ask for your feedback during placement of the electrodes.

Spinal Cord Stimulator Recovery

Most patients leave the same day as their procedure — once the anesthesia has worn off. For several days after surgery, your incisions may be painful. Try not to stretch, twist or reach, which could pull at the incisions. Dressings will be placed over the incision sites, which can be removed after about 3 days. In most cases, incisions heal within about 2-4 weeks after surgery.

Your doctor will discuss your recovery plan, but generally lighter activity is recommended for about 2 weeks after surgery.

Once your surgeon approves you for regular activity, you can return to work and drive again (with the stimulator turned off). This is typically 1-2 weeks after surgery.

Spinal Cord Stimulator Complications

Complications of spinal cord stimulator surgery are rare, but no procedure is without risk. A small percentage of patients may experience:

• Infection, which may occur in the first 2-8 weeks.
• Bleeding.
• Device migration (i.e., the electrodes move from their original location and the stimulator doesn’t block pain as effectively). This often requires a follow-up surgery to put the electrodes back in the proper spot.
• Device damage (e.g., a fall or intense physical activity breaks the stimulator).
• Dural puncture. The dura mater surrounds the spinal cord. Spinal cord stimulators are inserted in the epidural space, the area just outside the dura mater. If a needle or electrode goes too deep and pierces it, cerebrospinal fluid may leak out. These punctures can cause severe headaches.
• Spinal cord trauma. Although extremely rare, spinal cord stimulator insertion can cause nerve injury and paralysis.

Living with a Spinal Cord Stimulator

Generally, the pain relief provided by spinal cord stimulators allows patients to do much more than they could before surgery, but there are certain restrictions to be mindful of.

Can I have X-rays and CT scans with a spinal cord stimulator?

So long as your spinal cord stimulator is powered off, X-rays and CT scans are generally safe. Before undergoing any scan, always let your doctor, nurse or technician know you have a spinal cord stimulator.

Are spinal cord stimulators MRI compatible?

No, MRIs are not always safe for those with spinal cord stimulation devices. Some newer devices are compatible with certain MRI machine models and scan locations, but your doctor will need to evaluate the specifics of your stimulator first. If your device is not MRI compatible, MRIs can cause serious injury.

Communicate with your pain specialist beforehand so that he or she can weigh in on whether a procedure will interfere with or harm your stimulator model.

Will my spinal cord stimulator set off airport security?

Yes, airport security gates will detect your stimulator, but your physician will give you an identification card that may allow you to bypass the machine.

Some people find that airport security gates cause uncomfortable (but harmless) interference with their stimulators. If you cannot avoid passing through the security screener, turn off your device before stepping through.

Can I drive with a spinal cord stimulator?

No, you should power off your stimulator when you’re driving or operating heavy machinery, as sudden changes in stimulation levels could cause distraction.

Can I swim with a spinal cord stimulator?

Swimming is fine with a permanent, implanted generator, but you cannot get your temporary stimulator wet. You will need to avoid baths and showers during that short trial period.

Can a spinal cord stimulator be removed?

Yes, a spinal cord stimulator can be removed safely if you are unsatisfied with the level of pain relief it provides or if there is an infection or mechanical problem with your system. Learn more about spinal cord stimulator removal.