Who does nerve blocks low back pain



by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit


Information, in part, from the American Academy of Pain Medicine



The physician who does nerve blocks pretty much is dependent on who the patient is seeing for their problems.

Specialists who are skilled and trained in nerve block injections include neurosurgeons, orthopedic surgeons, physiatrists, and rheumatologists.

A patient should be sure to check the credentials and experience of the physician who is going to do their injections. How many have they done? That is the big question. Fewer than 100 is not good.

Epidural Steroid Injection (ESI)

An ESI is a common type of injection that is given to provide relief from low back pain and from certain types of neck pain. The "epidural space" is the space between the spinal sac (called the dura mater) and the inside of the bony spinal canal. It runs the entire length of your spine. Once injected into this area, the medication diffuses up and down the spine.

The skin where the injection will be performed will probably be injected with lidocaine first to numb the area.

The epidural needle is inserted into the back until the doctor feels sure it is in the epidural space. He or she will then place a small amount of lidocaine into the epidural space and wait to see if you feel warmth and numbness into your legs. If so, the needle is most likely in the correct position. The remainder of the medication is injected and the needle is withdrawn.

There are three different ways to perform an epidural injection:


Caudal Block

A caudal block is placed through the sacral gap (a space near the sacrum and below the lumbar spine), into the epidural space. This type of block usually affects the spinal nerves that are at the end of the spinal cord near the sacrum. This collection of nerves is also called the cauda equina. One of the benefits of this type of injection is less chance of a "dural puncture" also called a "wet tap". As mentioned above, the dura covers the spinal cord. It holds the spinal fluid and protects the cord and nerves from damage.

Translumbar
The most common way of performing an epidural is the translumbar approach. This type of injection is performed by placing a needle between two vertebrae from the back. The needle is inserted between the spinous processes of two vertebrae. You can actually feel the bumps that make up the spinous process by simply feeling along the back of your spine.

Transforaminal
This type of injection is a very selective injection around a specific nerve root. This type of epidural injection is used most often for diagnostic purposes, and it is commonly used in the neck. The foramina are the small openings between your vertebrae through which the nerve roots exit the spinal canal and enter the body. By injecting medication only around a specific nerve root, the doctor can determine if this is the nerve root causing the problem.



Indications to use an epidural:

It may be necessary to have several epidural injections in a series over a period of a few weeks. This is because the relief from the epidural injection usually decreases with time. It is not uncommon to have three lumbar epidural injections, each about ten days apart.

Epidural injections are good for reducing radicular pain caused by nerve irritation from herniated discs and spinal stenosis. Spinal stenosis is basically a narrowing of the entire spinal canal, which places pressure on the nerves and spinal cord. The injections are also helpful when the main problem is arthritis of the facet joints.

Difficulties

Technical Reasons
Your physician may suggest that an epidural injection not be considered if you have abnormalities of the epidural space; it has been altered from a congenital (present at birth) abnormality or from previous surgery that has left scarring.

Infection
Injecting steroids, such as cortisone, anywhere in the body, allows for absorption of the medication into the bloodstream and can lower the body's ability to fight infections. Cortisone should not be used if there is any type of serious infection in the body.

Steroid-Related
Absorption of the medication may also cause a whole body (systemic) corticosteroid effect such as fluid retention or interference with glucose control. Therefore, an epidural might not be well suited for patients with diabetes or congestive heart failure.



Risks

There are several risks involved with epidural injections to be aware of:

Dural Puncture
A dural puncture, or wet tap, is perhaps the most common complication from an ESI. This complication only occurs in 0.1 to 5 percent of all injections. The result of a dural puncture is usually a spinal headache and nausea. A spinal headache occurs when the puncture in the spinal sac fails to seal itself off. This allows the spinal fluid to continue to leak out and lowers the spinal fluid pressure in the brain. When sitting, the headache and nausea are much worse, because the spinal fluid pressure is lower at the top, near your head, than at the bottom of the spine. The headache usually goes away when you lie down with your feet higher than your head. To treat a spinal headache, a "blood patch" is usually recommended. If the doctor realizes immediately during the procedure he has a wet tap, he may perform a blood patch before he removes the epidural needle. A blood patch is a simple procedure where about three ounces of blood are drawn from an arm vein. The blood is then immediately injected into the epidural space with an epidural needle. The blood then clots around the spinal sac and stops the leak by forming a "patch".

Intravascular Injection
There is a small chance that the medication may be injected into one of the small blood vessels that run through the epidural space instead of the epidural space itself. This can cause seizures, cardiac arrest, and even death if too much of the medication goes directly into the blood steam. The chance of this happening is very low. Your doctor can discuss it with you in further detail.

Infection
Epidural injections are done under sterile conditions very similar to surgery. Still, anytime a needle is inserted into the body there is a small chance of infection. Since the needle in an epidural is going near the spine, an infection is much more serious if it occurs. The chance that an infection will occur is extremely small.

Bleeding
An epidural injection can result in a hematoma. A hematoma is simply a collection of blood due to an injury to a blood vessel. An epidural hematoma can be serious if it is big enough to cause enough pressure on the spinal nerves so that they quit working. This can cause problems with the bowels and bladder.

Bladder Dysfunction
Because the epidural injection actually paralyzes the nerves to the bowel and bladder for a short period, you may not have control over your bladder for one to two hours.

Neurologic Complications
There is always a small risk of damage to the spinal nerves. The spinal cord is a bundle of millions of nerves that connects the brain with the rest of the body. If the epidural needle directly injures the spinal nerves, this can cause neurologic problems.



Facet Joint Injections

Facet joint injections are used to localize and treat low back pain that is caused by problems of the facet joints. These joints are located on each side of the vertebrae; they join the vertebrae together and allow the spine to move with flexibility. The facet joint injections form a pain block that allows the doctor to confirm that it is a facet joint causing the pain. The medication used also decreases inflammation of the joint that occurs with arthritis and joint degeneration.

To insure that an injection is actually into the facet joint, "fluoroscopy" or ultrasound can be used to confirm that the needle is in the right position before the medication is injected.

There are two types of facet joint injections:

Interarticular - This is injected directly into the joint to block the pain and reduce inflammation.

Nerve Blocks - These help determine whether the joint is indeed a source of pain by blocking the medial branch or nerves that connect with the joint.

Indications to use a facet joint injection
A facet joint injection is perhaps the best way to diagnose facet joint syndrome. Joints that may look abnormal on an X-ray may in fact be painless, and joints that look fine may indeed be the source of the pain - only the injection tells the true story. These injections may be used to treat low back pain and determine whether the facet joints are the true culprits. It is also a rather simple procedure with low risk.



Hardware Injections

At times, your doctor may need to determine whether the metal hardware that has been used during surgery could be contributing to your discomfort. A hardware injection is performed by injecting lidocaine alongside the spinal hardware that was placed in the spine during surgery. If the pain is removed temporarily by the injection, it may indicate that the hardware is contributing to your pain.

Indications to use a hardware injection
The injections are used to determine whether a specific piece of hardware is contributing to the pain and needs to be removed surgically.



Sacroiliac Joint Injections

Sacroiliac joint (SI joint) pain is easily confused with back pain from the spine. The SI joint is located between the sacrum and the hipbone. In some cases, injecting the SI joint with lidocaine may help your doctor determine whether it is the source of your pain or not. If the joint is injected and your pain does not go away, it is probably coming from somewhere else. If the pain goes away immediately, your doctor may also inject cortisone into the joint before removing the needle. The cortisone is added to treat the inflammation from SI joint arthritis that may be causing your pain. The injection usually gives temporary relief for several weeks or months.

Indications to use a sacroiliac joint injection
SI joint injections can be used to treat and to prove that the SI joint is the source of pain. This injection usually requires the use of ultrasound guidance to make sure the needle is placed correctly in the joint.



Differential Lower Extremity Injections

Various types of injections into certain areas of the lower extremities can help your doctor decide where the pain is most likely coming from. Pain that comes from problems with the back and the spinal nerves can mimic many other conditions. Sometimes it is impossible to tell if the pain you are experiencing is due to a back condition or from a problem in your hip, knee, or foot. To try to determine whether the joint is causing you pain or not, your doctor may suggest injecting medication, such as lidocaine, into the joint to numb the area. Once the medication is injected, if the pain goes immediately away, that joint is more likely the source of the pain than your back. Your doctor can then focus on finding the problem in the joint, rather than your back.



General Contraindications to Blocks and Injections

Some basic reasons not to have spinal injections are:

Bleeding Tendencies
If you have a tendency to heavy bleeding or are on anticoagulant therapy (taking a medication that prevents blood clotting), you are not a good candidate for spinal injections. The physician giving the injection may ask that you stop all medications such as aspirin and ibuprofen five days before the injection. These medications can decrease the ability of the blood to clot and lead to problems. Make sure your provider has a list of your medications well ahead of your scheduled time for injection.

Infections
If you have a local or systemic infection, a spinal injection may put you at greater risk for spreading the infection into the spine causing meningitis. Make sure you tell your health care provider if you have any infected wounds, boils, or rashes anywhere on your body.

Unstable Medical Conditions
Injections are usually an elective procedure that is offered to patients without life-threatening conditions. A medically unstable patient should have their medical condition treated before any elective injections are given.



General Precautions

The following are basic warnings to consider before choosing to have a spinal injection:

If you are chronically taking a platelet-inhibiting drug, such as aspirin or NSAIDs (nonsteroidal anti-inflammatory drugs), you have an increased risk of bleeding and might not be a candidate for a spinal injection.

If you are hypersensitive or have certain allergies to medications, you may have a negative reaction to drugs used in the injection. Make sure you give your provider a list of your allergies.

If you have an accompanying medical illness, you should discuss the risks of spinal injections with your physician. For example, patients with diabetes mellitus might experience an increase in blood sugar after an injection with cortisone. Patients with congestive heart failure, renal failure, hypertension, or a significant cardiac disease may have problems because of the effects of fluid retention several days after an injection.




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