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Pain Clinic Procedures
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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.
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, nerve 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.
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:-
This medication is actually derived from a bacteria that produces the deadly poison botulism.
As a result of using it in dermatology, it was found to be an effective pain reliever for both migraine and tension headaches. Subsequently it was licensed for use in the US in the late Eighties.
Botox® is used in a purified and diluted form and temporarily causes muscles to relax, thus relieving pain. In effect it is a muscle weakening agent that results in a disconnection of the nerve from the muscle.
It can be very effective as a pain reliever in many types of chronic pain and conditions such as Multiple Sclerosis.
For cases of chronic lower back pain that has not responded to other treatments, Botox® can also be very effective. It works by reducing muscle spasm, and therefore allows a greater tolerance to other treatments, such as physical therapy / exercise. It is suggested that after a period of time the muscles get stronger and patients avoid the need for future injections.
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.
This page was last updated on the 9th May 2002. The content of this website may be freely produced. This template for this site was kindly designed by Bob Wood. Webmaster Stephen R Wilson RMN DPSN, contact steve@coping.org.uk