Non-Invasive and Minimally-Invasive Treatments
Table of Contents:
Minimally Invasive Surgery: Selective Endoscopic Discectomy (SED)
Epidural Steroid Injections
(Cervical,Thoracic & Lumbar)
Epidural steroid injection is an effective minimally invasive treatment for some patients with low back or leg pain due to nerve impingement. Commonly, nerves which supply the back or legs are compressed near the spine either by a bulging disc, a bone spur, or by scar tissue. This causes the nerve to become irritated, inflamed and swollen. Cortisone is a powerful anti-inflammatory with the ability to decrease swelling and inflammation in this nerve, thus breaking the vicious cycle of swelling and irritation. The procedure is performed using fluoroscopy (x-ray guidance) so that the medication can be placed precisely where the physician feels it will be most effective.
Following this procedure, some patients feel a warmth or numbness in their legs from the effects of the local anesthetic. You should not drive for the remainder of the day since it is possible to have some residual weakness in your legs for a few hours. Relief from the injection generally takes about three days although some patients feel relief immediately and others do not feel relief up to a week or so. During the first few days after the injection, it is common to feel increased back discomfort from the effect of the needle having been placed. Side effects such as headache occur in less than 1% of patients. More serious complications such as infection can occur but they are exceedingly rare.
About 70% of patients who have not had previous back surgery obtain relief from epidural steroid injections. For patients who have had previous back surgery, the results are somewhat less. Many patients obtain permanent relief after one injection, but others find that their pain relief plateaus or that their pain recurs weeks, months or years later. Some patients obtain no substantial relief from the injection.
Additional testing is required to assign a “pain generator” status to the individual disc. Discography is accepted as the disc evaluation “procedure-of-choice”. Discography investigates, and establishes the intervertebral discs role in the production of the patient’s low back pain. At times in the past the value of discography has been questioned. Current literature supports discography’s worth as a diagnostic tool used to investigate painful spinal conditions.
Who is a candidate and when is discography indicated?
- A patient who experiences persistent spinal (cervical, thoracic, lumbar) pain
- A disc abnormality is suspected
- Non-invasive tests have failed to provide an explanation or source of pain
Patients who have continued pain despite previous surgery are often discography candidates.
Provocative discography is the instillation of sterile saline (not dye) into the disc looking for reproduction of the patient’s pain. Exact pain reduction supports the discs role as a “pain generator”, documenting a specific diagnosis, and allows more aggressive intervention.
Indications for Discography
We believe in the following indication, for discography:
- Failed conservative therapy
- Diagnostic tests – inconclusive (equivocal or inconsistent)
- Persistence of severe symptoms – surgery a consideration
Discography is an outpatient procedure, performed under fluoroscopy, local anesthesia and sterile conditions. When performed correctly and in “experienced hands” the main complication is a short period of increased pain. In short, discography has proven itself to be an invaluable diagnostic modality reserved for the investigation of painful spinal conditions where other non-invasive studies have been unable to provide or confused the diagnosis to allow further more aggressive treatment.
Radio Frequency (RF) Nerve Ablation (also known as RF Rhizotomy) is a therapeutic procedure designed to decrease or eliminate pain symptoms within spinal facets by temporarily deactivating minor nerves around the spine. The pain generating nerves for many patients are often small, unimportant fibers which can cause severe pain. These nerves can be temporarily shut down using radiofrequency energy to heat the surrounding tissue and deactivate the pain generating nerve fibers. The procedure is performed by accessing the affected nerve under x-ray guidance. Once properly positioned, a special probe is advanced allowing the delivery of radiofrequency energy to the targeted area. An electric current is then used to cauterize the sensory nerves that innervate the facet joint(s).
Before patients can be scheduled for an RF rhizotomy procedure, they generally must undergo a series of facet injections to verify the exact source of their symptoms. These tests may require several visits. If a patient’s pain can be taken away or significantly relieved with a local anesthetic block for a short term, then blocking the nerves with Radiofrequency denervation will usually give long term or even permanent relief. If successful, the pain relief following an RF procedure can last considerably longer than relief following local anesthetic and steroid blocks (Results can last from months to years.)
This process can be used on any area of the spine–cervical, thoracic, or lumbar. Due to the trauma to the nerve, you may experience an increase in symptoms for 5-7 days after the procedure. Pain relief benefits should be apparent within 2-4 weeks.
This procedure is otherwise known as epidural lysis of adhesions or the “RACZ” procedure after the physician who first performed the procedure.
It has been found that after trauma or surgery of the spine, scar tissue forms around the nerves in the spinal canal. It has also been shown that the presence of scar tissue compounded pain associated with nerve roots by adhering the nerve roots to one position and thus increasing the nerve root to tension or compression. This active insult to nerve roots cause significant intraneural edema, or swelling in the nerve root itself. Pain can also result from the nerve endings found throughout the spinal canal and associated structures.
Epidural Neuroplasty or Epidural Neurolysis is a procedure to help identify significant epidural adhesion and fibrosis, whether from trauma to the spinal structures or from corrective surgery itself. By using 1) anti-inflammatory medication, 2) medications aimed at reducing edema, 3) local anesthetics to block nerves that carry pain information to the brain, and 4) fluid and special medications to break down scarring around the spinal nerves and structures. There is rational to target the anterior epidural space.
The procedure itself is done as an outpatient, under light sedation and x-ray guidance. There are several variations on the procedure, some involving inpatient admissions and several different medications. Your physician will discuss this with you and how it applies to your particular situation. Several different approaches to the scarring are possible, sometimes utilizing both approaches at the same time. During the lysis of the adhesions, pain can sometimes be felt into the back, buttocks or into the legs. This is due to the pressure of the scarring on the nerves. Occasionally postoperative pain can be felt for up to one week. With the reduction of pain, your physician will occasionally start physical therapy.
As with any procedure, there are potential complications. The most common complication of Epidural Neuroplasty is unintended subarachnoid injection. Others may include bleeding, infection, bladder dysfunction, and transient motor weakness. There is a small chance of hypersensitivity to hyaluronidase, which can be used during the treatment.
Outcomes: With treatment that includes hyaluronidase, up to 80% of patients report some pain relief, with a significant number reporting long-term pain relief.
Nerve Block Therapy
The nervous system controls both conscious functions, which are under our control, and unconscious functions which occur automatically. When nerves are injured, whether by trauma or as a result of illnesses like diabetes, pain can result. This is called neuropathic pain. Often injecting local anesthetics or anti-inflammatory steroid medicines around the injured nerves can result in pain relief. This relief can be temporary, but in some cases can lead to permanent improvement. The purpose for doing nerve blocks can be diagnostic: the injection is a test to see if the pain is coming from the nerve being blocked. It can also be done in an attempt to permanently relieve or decrease pain. Sometimes in injured nerves the pain is learned by the nervous system, and the blocks are an attempt to help the nervous system relearn its normal, pain-free state. Sometimes the pain is caused by a nerve being trapped in scar tissue, and the injections are performed to try to loosen the scar tissue away from the nerve.
This neurolysis by injection can be effective with less risk than surgical exploration. A series of anywhere from three to six blocks, occasionally more, is usually necessary for both of these conditions. These blocks do not always succeed in giving permanent relief, in fact if after a few blocks your doctor does not see a steady improvement he may try alternative therapy, including medications and physical therapy, but also possibly surgery. If the pain cannot be eliminated, then your treatment will be directed at relaxation techniques to diminish pain, at rehabilitation to maintain function, and at oral medication to desensitize the nervous system. The success of nerve block therapy depends on how well established the problem is, and how much damage to the nerve has already occurred. Sometimes improvement is seen in function but not in pain, or vice versa.
Platelet-Rich Plasma (PRP) Therapy
This non-invasive, non-surgical procedure is increasing in popularity as a new form of treatment for a variety of musculoskeletal problems.
For this procedure, the doctor will take a portion of blood from the patient, and put that blood in a centrifuge, which concentrates the platelets. Platelets are known to accelerate and direct the healing of many tissues, such as ligaments, muscles and bones, by secreting what are called growth factors that stimulate growth in other cells.
The doctor will then inject a dose of the platelet-rich plasma into the injured area of the patient.
PRP therapy often gets attention in the media as a therapy common in the professional sports world. But as science continues to discover its effectiveness, more and more people in all walks of life are benefiting from it.
At the SMART Clinc, we provide individualized PRP therapy for a variety of spine and sports-related injuries, including disk injection therapy and post-surgery therapy for ligaments and tendons.
Facet Joint Injections
These injections, often referred to as “facet blocks”, can effectively break the cycle of pain which becomes chronic if left untreated. Injections can be targeted to cervical, thoracic, and lumbar areas across the entire spine from neck to lower back depending on the nerve involved. This prodedure uses contrast dye to pinpoint the source of pain within the facet joints of the spine. It also uses therapeutic steroids and local anesthetic to decrease the pain and inflammation that may be present in this area. Pain relief from a facet joint injection procedure varies from minimal to long-term, depending on the specific symptoms. The procedure takes 10-30 minutes and you will be asked to wait 30-40 minutes after your procedure before leaving. Using a thin needle and fluoroscopy (x-ray) for guidance, the physician will place contrast, anesthetic, and steroid into the facet joint. During the procedure you may feel some slight pressure or discomfort. The doctor will be interested in how this discomfort compares to your usual pain symptoms. In addition, he will want you to keep track of any changes in your pain symptoms in the days and weeks following the injection in order to evaluate the effectiveness of the treatment.Due to the effects of certain medications, your driving reflexes may be impaired. Consequently, you will need someone to drive you home after your exam.
Sacroilliac Joint Injections
A sacroiliac joint injection is an injection of an anesthetic with a long lasting steroid in the Sacroiliac joints. The sacroiliac joints are located in the back where the lumbosacral spine joins the pelvis. They are paired (right and left) and are surrounded by a joint capsule like the finger joints. The steroid injected reduces the inflammation in the joint space. This can reduce pain, and other symptoms caused by inflammation. The actual injection takes only a few minutes. The injection consists of a mixture of local anesthetic and the steroid medication . Many times prior to injecting the medicine, a small volume of contrast dye is used to confirm proper needle placement. It is done with the patient lying on the stomach with fluoroscopic (x-ray) guidance.
Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last for a few hours. Your pain may return and you may have a sore back or neck for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 3rd to 5th day. You should have a ride home. We advise patients to take it easy for the day of the procedure. You may want to apply ice to the affected area. After the first day, you can perform activity as tolerated. Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is soreness in the neck or back. The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The medication starts working in about 5 to 7 days and its effect can last for several days to many months. This procedure is safe when performed in a controlled setting (surgical center, sterile equipment, and the use of x-ray.) However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is discomfort – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms. As with other types of injections, you should not have the procedure if you are currently taking blood-thinning medicine (Coumadin.) Side effects related to cortisone include: fluid retention, weight gain, increased blood sugar (mainly in diabetics,) elevated blood pressure, mood swings, irritability, insomnia, and suppression of body’s own natural production of cortisone. Fortunately, the serious side effects and complications are uncommon. You should discuss any specific concerns with your physician.
Minimally Invasive Surgery: Selective Endoscopic Discectomy (SED)
Selective Endoscopic Discectomy (or Percutaneous Discectomy Microdecompressive Endoscopic Lumbar Discectomy with Laser Thermodiskoplasty) is a new procedure to shrink and remove herniated disc.Using local anesthesia and the help of x-rays for guidance, specially designed micro-instruments, the discectome and a laser probe are inserted into the herniated disc space and the disc is removed by suction, and then shrunk by the laser, instead of the open surgery. Selective Endoscopic Discectomy is different from standard lumbar disc surgery because there is no muscle dissection or bone removal. There is only one tiny incision to accommodate the micro-instruments, inserted into the herniated disc. Most complications that occur with surgery are eliminated with selective lumbar endoscopic discectomy.
This minimally invasive spine surgery is performed under local anesthesia with the patient awake and in a lateral position. A small needle is inserted into the disc space after local anesthesia has been administered. Over this needle, a slightly larger probe is inserted to permit a 2mm incision to be made in the disc itself. Under x-ray and fluoroscopic control, the micro-instruments (mini forceps, mini curettes, trephines, rasps, burrs, and mini cutters), the discectome and the laser probe are used for disc removal. Very small pieces of the disc material are removed and suctioned into the tip of the discectome and then cut by its knife. The laser is used for further removal of the disc and for further shrinkage, for the purpose of disc decompression. The procedure takes about 30 minutes to an hour, on the average. X-ray exposures are minimal.The amount of disc removed and shrinkage by the laser varies, but includes the herniated portion. The supporting structure of the disc is not affected. Upon completion, the needle is removed and a small Band-Aid is applied over the needle incision.
The patient may feel relief from pain immediately following this minimally invasive back surgery. This is an outpatient procedure.Walking and exercising is usually encouraged on the same day. Some patients experience lower back muscle spasms that generally can be relieved with relaxants and analgesics. Pain in the area of the operation is usually minimal and requires no medication. From the day of discharge, a daily exercise program is recommended and there is a reevaluation several days later. Little, if any, postoperative medication is required for most patients. Normal activities can usually be resumed at the doctor’s discretion within one to six weeks.
The primary advantage of this procedure is that there is no interference with the muscles, bones, joints or manipulation of the nerves in the low back area. Since insertion of the instruments through the muscle is the only wound, there is no scarring in or around the nerves postoperatively. Additionally, it is an outpatient procedure. Also, the laser can further shrink the bulging disc. All patients are not relieved of their pain with this procedure, but approximately 90 percent of patients have experienced pain relief. Patients who do not obtain relief within three to six weeks may be considered for microsurgical disc removal, depending on the circumstances. There does not appear to be any detrimental effect from performing Selective Endoscopic Discectomy.
Results with Selective Endoscopic Discectomy indicate no hospitalization requirement, earlier return to work and earlier return to previous daily activities. Rare patient complications include muscle spasms of lower back. A small percentage of patients do not get relief of symptoms. Patients who initially have obtained good results appear to remain pain free.
Endoscopic Discectomy is an important part of the minimally invasive spine surgery (MISS) movement.