About Chronic Pain Relief

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Information and Videos

The experts at My Pain KY are dedicated to finding the source and cause of your pain and helping you achieve your best functional lifestyle. We want you to be fully informed about the cause of your pain and how it is being treated. Your condition may also change with time or treatments. Our recommendations, too, may change, based on your situation.

Symptoms of CFS include malaise after exertion; unrefreshing sleep, widespread muscle and joint pain, sore throat, headaches of a type not previously experienced, cognitive difficulties, chronic and severe mental and physical exhaustion, and other characteristic symptoms in a previously healthy and active person. Additional symptoms may be reported, including muscle weakness, increased sensitivity to light, sounds and smells, orthostatic intolerance, digestive disturbances, depression, painful and often slightly swollen lymph nodes, cardiac and respiratory problems. It is unclear if these symptoms represent co-morbid conditions or if they are produced by an underlying etiology of CFS. CFS symptoms vary in number, type, and severity from person to person. Quality of life of persons with CFS can be extremely compromised. CFS can begin gradually, usually following a period of severe physical or emotional stress.

Treatment

Treatment for chronic fatigue syndrome focuses on symptom relief. Medications used to treat chronic fatigue include:

The exact cause of depression is not known. It is believed to be linked to an imbalance of chemicals in the brain. Hormone fluctuations and genetic predisposition may play a role. Environmental factors such as stress, loss of a loved one, or long-term physical or emotional abuse may also contribute to depression. Depression can be caused from chronic pain and fatigue as well as dysfunction in ability to achieve self care and daily activity.

Symptoms

Symptoms of depression can include uncontrollable feelings of sadness or hopelessness, irritability, difficulty sleeping, and an inability to concentrate. Symptoms may also include aches and pains, weight fluctuations and lethargy. A person who has depression may lose interest in activities or hobbies that were previously enjoyable. The person may lose interest in sex, and may have suicidal thoughts. Pain can worsen in the situation of chronic pain and depression.

Diagnosis

Depression is diagnosed with a series of physical exams, lab tests, and psychological evaluations. The physical exams and lab tests can help identify physical problems. These tests can also screen for alcohol or drug abuse. The psychological evaluations can help a physician understand the severity and frequency of symptoms, and the mental health history of the patient and the patient’s family.

Treatment

Depression is treated with medications to regulate hormones and brain chemistry. It is also treated with psychotherapy. Patients who don’t respond to these methods may benefit from electroconvulsive therapy (ECT). A person with severe depression may need to be hospitalized. Repeated or ongoing treatment may be needed. Depression needs to be treated as well as chronic pain as both may be contributing factors to the worsening of the other. Periodic screening for depression in the setting of chronic pain can help the patient achieve functionality faster in most cases.

Degenerative Disc Disease

Overview

Symptoms

One sign of a frozen shoulder is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. The movement that is most severely inhibited is external rotation of the shoulder.
People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion, or if bumped. A physical therapist or chiropractor may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder). An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.
The normal course of a frozen shoulder has been described as having three stages.

• Stage one: The “freezing” or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.
• Stage two: The “frozen” or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months.
• Stage three: The “thawing” or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.

Treatment

Treatment for frozen shoulder usually starts with nonsteroidal anti-inflammatory drugs (NSAIDs) and application of heat to the affected area, followed by gentle stretching. Ice and medicines (including corticosteroid injections into muscle trigger points) may also be used to reduce pain and swelling. And physical therapy can help increase your range of motion. A frozen shoulder can take many months to get better. But if treatment is not helping, injection with ultra sound guidance into the joint may be helpful in restoring movement while decreasing pain and discomfort. If conservative management and injection therapy is not restoring function arthroscopic surgery is rarely sometimes done to cut some of the tight tissues around the shoulder.

Treatment may be painful and taxing and consists of physical therapy, occupational therapy, Chiropractic, medication, massage therapy, hydrodilatation or surgery. A doctor may also perform manipulation under anesthesia, which breaks up the adhesions and scar tissue in the joint to help restore some range of motion. Pain and inflammation can be controlled with analgesics and NSAIDs. The condition tends to be self-limiting: it usually resolves over time without surgery, but this may take up to two years. Most people regain about 90% of shoulder motion over time. People who suffer from adhesive capsulitis may have extreme difficulty working and going about normal life activities for several months or longer.

Herniated Discs

Overview

A herniated disk refers to a problem with one of the rubbery cushions (disks) between the individual bones (vertebrae) that stack up to make your spine. A spinal disk is a little like a jelly donut, with a softer center encased within a tougher exterior. Sometimes called a slipped disk or a ruptured disk, a herniated disk occurs when some of the softer “jelly” pushes out through a crack in the tougher exterior. A herniated disk can irritate nearby nerves and result in pain, numbness or weakness in an arm or leg. On the other hand, many people experience no symptoms from a herniated disk. Most people who have a herniated disk don’t need surgery to correct the problem.

Why it Occurs

In many cases, a herniated disk is related to the natural aging of your spine. In children and young adults, disks have a high water content. As we get older, our disks begin to dry out and weaken. The disks begin to shrink and the spaces between the vertebrae get narrower. This normal aging process is called disk degeneration.
Risk Factors
In addition to the gradual wear and tear that comes with aging, other factors can increase the likelihood of a herniated disk. Knowing what puts you at risk for a herniated disk can help you prevent further problems.
Gender. Men between the ages of 30 and 50 are most likely to have a herniated disk.
Improper lifting. Using your back muscles to lift heavy objects, instead of your legs, can cause a herniated disk. Twisting while you lift can also make your back vulnerable. Lifting with your legs, not your back, may protect your spine.
Weight. Being overweight puts added stress on the disks in your lower back.
Repetitive activities that strain your spine. Many jobs are physically demanding. Some require constant lifting, pulling, bending, or twisting. Using safe lifting and movement techniques can help protect your back.
Frequent driving. Staying seated for long periods, plus the vibration from the car engine, can put pressure on your spine and disks.
Sedentary lifestyle. Regular exercise is important in preventing many medical conditions, including a herniated disk.
Smoking. It is believed that smoking lessens oxygen supply to the disk and causes more rapid degeneration.

Symptoms

For most people with a herniated disk, low back pain is the initial symptom. This pain may last for a few days, then improve. It is often followed by the eventual onset of leg pain, numbness, or weakness. This leg pain typically extends below the knee, and often into the foot and ankle. It is described as moving from the back or buttock down the leg into the foot.
Symptoms may be one or all of the following:
• Back pain
• Leg and/or foot pain (sciatica)
• Numbness or a tingling sensation in the leg and/or foot
• Weakness in the leg and /or foot
• Loss of bladder or bowel control (extremely rare) This may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed. It requires immediate medical attention.
Not all patients will experience pain as a disk degenerates. It remains a great challenge for the doctor to determine whether a disk that is wearing out is the source of a patient’s pain.

Treatment

In the majority of cases, a herniated lumbar disk will slowly improve over a period of several days to weeks. Typically, most patients are free of symptoms by 3 to 4 months. However, some patients do experience episodes of pain during their recovery.

Nonsurgical Treatment
Unless there are neurological deficits — muscle weakness, difficulty walking — or cauda equina syndrome, conservative care is the first course of treatment. Because it is not clear that nonsurgical care is any better than letting the condition resolve on its own, the focus is on providing pain relief.
Common nonsurgical measures include:
Rest. Usually 1-2 days of bed rest will calm severe back pain. Do not stay off your feet for longer, though. Take rest breaks throughout the day, but avoid sitting for long periods of time. Make all your movements slow and controlled. Change your daily activities so that you avoid movements that can cause further pain, especially bending forward and lifting.
Anti-inflammatory medications. Medicines like ibuprofen or naproxen may relieve pain.
Physical therapy. Specific exercises can strengthen your lower back and abdominal muscles.
Epidural steroid injection. In this procedure, steroids are injected into your back to reduce local inflammation. This can be done in the cervical area as well.
Of the above measures, only epidural injections have been proven effective at reducing symptoms. There is good evidence that epidural injections can be successful in 42-56% of patients who have not been helped by 6 weeks or more of other nonsurgical care.
Overall, the most effective nonsurgical care for lumbar herniated disk includes observation and an epidural steroid injection for short-term pain relief.

Hip Bursitis

Overview

Hip bursitis is a common problem that causes pain over the outside of the upper thigh and hip joint. A bursa is a fluid filled sac that allows smooth motion between two surfaces. For example, in the hip, a bursa rests between the bony prominence over the outside of the hip (the greater trochanter) and the firm tendon that passed over this bone. When the bursa becomes inflamed, each time the tendon has to move over the bone, pain results. Because patients with hip bursitis move this tendon with each step, symptoms of this condition can be quite painful.

Why it Occurs

Trochanteric bursitis can result from one or more of the following events:

Injury to the point of the hip. This can include falling onto the hip, bumping the hip into an object, or lying on one side of the body for an extended period.
Play or work activities that cause overuse or injury to the joint areas. Such activities might include running up stairs,climbing, or standing for long periods of time.
Incorrect posture. This condition can be caused by scoliosis, arthritis of the lumbar (lower) spine, and other spine problems.
Stress on the soft tissues as a result of an abnormal or poorly positioned joint or bone (such as leg length differences or arthritis in a joint).
Other diseases or conditions. These may include rheumatoid arthritis, gout, psoriasis, thyroid disease or an unusual drug reaction. In rare cases,bursitis can result from infection.
Previous surgery around the hip or prosthetic implants in the hip.
Hip bone spurs or calcium deposits in the tendons that attach to the trochanter.
Bursitis is more common in women and in middle-aged or elderly people. Beyond the situations mentioned above, in many cases, the cause of trochanteric bursitis is unknown.

Symptoms

Trochanteric bursitis typically causes the following symptoms:

Pain on the outside of the hip and thigh or in the buttock.
Pain when lying on the affected side.
Pain when you press in on the outside of the hip.
Pain that gets worse during activities such as getting up from a deep chair or getting out of a car.
Pain with walking up stairs.

Treatment

Treatment goals include reducing pain and inflammation, preserving mobility, and preventing disability and recurrence. Treatment recommendations may include a combination of rest, splints, heat, and cold application. More advanced treatment options include:

Nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen
Corticosteroid injections given by your health care provider. Injections work quickly to decrease the inflammation and pain.
Physical therapy that includes range of motion exercises and splinting. This can be very beneficial.
Surgery, when other treatments are not effective.

Insomnia

Overview

Patients suffering from chronic pain often find that their problems are compounded by the additional difficulties that come with insomnia and sleeping disorders. Of those who report experiencing chronic pain, approximately 65% report having sleep disorders, such as disrupted or non-restorative sleep.
In a recent study, it was found that approximately two-thirds of patients with chronic back pain suffered from sleep disorders. Research has demonstrated that disrupted sleep will, in turn, exacerbate the chronic back pain problem. Thus, a vicious cycle develops in which the back pain disrupts one’s sleep, and difficulty sleeping makes the pain worse, which in turn makes sleeping more difficult, etc.

Why it Occurs

Common causes of insomnia include:
• Stress. Concerns about work, school, health or family can keep your mind active at night, making it difficult to sleep. Stressful life events, such as the death or illness of a loved one, divorce or a job loss, may lead to insomnia.
• Anxiety. Everyday anxieties as well as more-serious anxiety disorders may disrupt your asleep.
• Depression. You might either sleep too much or have trouble sleeping if you’re depressed. This may be due to chemical imbalances in your brain or because worries that accompany depression may keep you from relaxing enough to fall asleep. Insomnia often accompanies other mental health disorders as well.
• Medications. Many prescription drugs can interfere with sleep, including some antidepressants, heart and blood pressure medications, allergy medications, stimulants (such as Ritalin) and corticosteroids. Many over-the-counter (OTC) medications, including some pain medication combinations, decongestants and weight-loss products, contain caffeine and other stimulants. Antihistamines may initially make you groggy, but they can worsen urinary problems, causing you to get up to urinate more during the night.
• Caffeine, nicotine and alcohol. Coffee, tea, cola and other caffeine-containing drinks are well-known stimulants. Drinking coffee in the late afternoon and later can keep you from falling asleep at night. Nicotine in tobacco products is another stimulant that can cause insomnia. Alcohol is a sedative that may help you fall asleep, but it prevents deeper stages of sleep and often causes you to awaken in the middle of the night.
• Medical conditions. If you have chronic pain, breathing difficulties or a need to urinate frequently, you might develop insomnia. Conditions linked with insomnia include arthritis, cancer, heart failure, lung disease, gastroesophageal reflux disease (GERD), overactive thyroid, stroke, Parkinson disease and Alzheimer’s disease. Making sure that your medical conditions are well treated may help with your insomnia. If you have arthritis, for example, taking a pain reliever before bed may help you sleep better.
• Change in your environment or work schedule. Travel or working a late or early shift can disrupt your body’s circadian rhythms, making it difficult to sleep. Your circadian rhythms act as internal clocks, guiding such things as your sleep-wake cycle, metabolism and body temperature.
• Poor sleep habits. Habits that help promote good sleep are called sleep hygiene. Poor sleep hygiene includes an irregular sleep schedule, stimulating activities before bed, an uncomfortable sleep environment and use of your bed for activities other than sleep or sex.
• ‘Learned’ insomnia. This may occur when you worry excessively about not being able to sleep well and try too hard to fall asleep. Most people with this condition sleep better when they’re away from their usual sleep environment or when they don’t try to sleep, such as when they’re watching TV or reading.
• Eating too much late in the evening. Having a light snack before bedtime is OK, but eating too much may cause you to feel physically uncomfortable while lying down, making it difficult to get to sleep. Many people also experience heartburn, a backflow of acid and food from the stomach into the esophagus after eating. This uncomfortable feeling may keep you awake.

Symptoms

Insomnia and aging
Insomnia becomes more common with age. As you get older, changes can occur that may affect your sleep. You may experience:
• A change in sleep patterns. Sleep often becomes less restful as you age, and you may find that noise or other changes in your environment are more likely to wake you as you get older. With age, your internal clock often advances, which means you get tired earlier in the evening and wake up earlier in the morning. But older people generally still need the same amount of sleep as younger people do.
• A change in activity. You may be less physically or socially active. Activity helps promote a good night’s sleep. You may also be more likely to take a daily nap, which also can interfere with sleep at night.
• A change in health. The chronic pain of conditions such as arthritis or back problems as well as depression, anxiety and stress can interfere with sleep. Older men often develop noncancerous enlargement of the prostate gland (benign prostatic hyperplasia), which can cause the need to urinate frequently, interrupting sleep. In women, hot flashes that accompany menopause can be equally disruptive.
Other sleep-related disorders, such as sleep apnea and restless legs syndrome, also become more common with age. Sleep apnea causes you to stop breathing periodically throughout the night. Restless legs syndrome causes unpleasant sensations in your legs and an almost irresistible desire to move them, which may prevent you from falling asleep.
• Increased use of medications. Older people use more prescription drugs than younger people do, which increases the chance of insomnia caused by a medication.

Treatment

The moderately positive relationship between pain severity and sleep complaints, and the specificity of pain-related arousal and mediating variables such as depression, illustrate that insomnia in relation to chronic pain is multifaceted and poorly understood. This may explain the limited success of the available treatments. Non-pharmacological interventions should not be considered as single interventions, but in association with one another.

Some non-pharmacological interventions especially the cognitive and behavioral approaches, can be easily implemented in general practice (e.g. stimulus control, sleep restriction, imagery training and progressive muscle relaxation).

Hypnotics are routinely prescribed in the medically ill, regardless of their adverse effects; however, their long-term efficacy is not supported by robust evidence. Antidepressants provide an interesting alternative to hypnotics, since they can improve pain perception as well as sleep disorders in selected patients. Sedative antipsychotics can be considered for sleep disturbances in those patients exhibiting psychotic features, or for those with contraindications to benzodiazepines. Low doses of sedative antipsychotics may improve chronic insomnia in the elderly. However, no intervention is likely to be effective unless a good physician-patient relationship is developed.[1]

In addition to pain in the phantom limb, some people experience other sensations such as tingling, cramping, heat, and cold in the portion of the limb that was removed. Any sensation that the limb could have experienced prior to the amputation may be experienced in the amputated phantom limb.

Treatment

Successful treatment of phantom limb pain is difficult. Treatment is usually determined based on the person’s level of pain, and multiple treatments may be combined. One approach that has gained a great deal of public attention is the mirror box developed by Vilayanur Ramachandran and colleagues. Through the use of artificial visual feedback it becomes possible for the patient to “move” the phantom limb, and to unclench it from potentially painful positions. Repeated training in some subjects has led to long-term improvement.

Some more standard treatments include:
•Heat application
•Biofeedback to reduce muscle tension
•Relaxation techniques
•Massage of the amputation area
•Surgery to remove scar tissue entangling a nerve
•Physical therapy
•TENS (transcutaneous electrical nerve stimulation) of the stump
•Neurostimulation techniques such as spinal cord stimulation or deep brain stimulation
•Medications such as pain-relievers, neuroleptics, anticonvulsants, antidepressants, beta-blockers, and sodium channel blockers.

Piriformis Syndrome

Overview

Piriformis syndrome is a condition in which the piriformis muscle, located in the buttock region, spasms and causes buttock pain. The piriformis muscle can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain.

Why it Occurs

The piriformis muscle:
• Starts at the lower spine and connects to the upper surface of each femur (thighbone).
• Functions to assist in rotating the hip and turning the leg and foot outward.
• Runs diagonally, with the sciatic nerve running vertically directly beneath it (although in some people the nerve can run through the muscle).
The exact causes of piriformis syndrome are unknown. Suspected causes include:
• Muscle spasm in the piriformis muscle, either because of irritation in the piriformis muscle itself, or irritation of a nearby structure such as the sacroiliac joint or hip.
• Tightening of the muscle, in response to injury or spasm.
• Swelling of the piriformis muscle, due to injury or spasm.
• Bleeding in the area of the piriformis muscle.
Any one or combination of the above problems can affect the piriformis muscle (causing buttock pain) and may affect the adjacent sciatic nerve (causing pain, tingling, or numbness in the back of the thigh, calf, or foot).

Symptoms

Most commonly, patients describe acute tenderness in the buttock and sciatica-like pain down the back of the back of the thigh, calf and foot. Typical piriformis syndrome symptoms may include:
• A dull ache in the buttock
• Pain down the back of the thigh, calf and foot (sciatica)
• Pain when walking up stairs or inclines
• Increased pain after prolonged sitting
• Reduced range of motion of the hip joint
Symptoms of piriformis syndrome often become worse after prolonged sitting, walking or running, and may feel better after lying down on the back.

Treatment

In addition to basic stretching, a comprehensive physical therapy and exercise program can be developed for each patient’s individual situation. A number of stretching exercises for the piriformis, hamstrings and hip extensors may help decrease the painful symptoms along the sciatic nerve and return the patient’s range of motion. The basic stretches include:
Piriformis stretch
There are a number of ways to stretch ones piriformis muscle. Two simple ways include:
• Lie on ones back with both feet flat on the floor and both knees bent. Pull the right knee up to the chest, grasp the knee with the left hand and pull it towards the left shoulder and hold the stretch. Repeat for each side.
• Lie on the back with both feet flat on the floor and both knees bent. Rest the ankle of the right leg over the knee of the left leg. Pull the left thigh toward the chest and hold the stretch. Repeat for each side.
Each piriformis stretch should be held for 5 seconds to start, and gradually increased to hold for 30 seconds, and repeated three times each day

Hamstring stretch for sciatic nerve pain
Stretching the hamstrings (the large muscle along the back of each thigh) is important to alleviate any type of sciatic pain. There are a number of ways to stretch the hamstrings:
• Place two chairs facing each other. Sit on one chair and place the heel of one leg on the other chair. Lean forward, bending at the hips until a gentle stretch along the back of the thigh is felt, and hold the stretch.
• Lie on the back with both legs straight. Pull one leg up and straighten by holding on to a towel that is wrapped behind the foot until a mild stretch along the back of the thigh is felt.
Again, try to work up to holding each stretch for 30 seconds and repeat three times each day.

For severe sciatica pain from piriformis syndrome, an injection may be part of the treatment.
Piriformis injection
A local anesthetic and corticosteroid may be injected directly into the piriformis muscle to help decrease the spasm and pain. The purpose of an injection is usually to decrease acute pain to enable progress in physical therapy.
Botox injection
For persistent piriformis spasm that is resistant to treatment with anesthetic/corticosteroid injections, an injection of botulinum toxin (e.g. Botox®), a muscle weakening agent, may be useful. The goal of the injection is to help the muscle relax and help reduce pressure on the sciatic nerve.
The goal with both injections is to help the patient progress with stretching and physical therapy, so that when the effect of the injection is over the muscle will be remain stretched and relaxed.

Post Laminectomy Syndrome

Overview

Post-Laminectomy Syndrome is also referred to as failed back syndrome and is characterized by residual and persistent back and/or leg pain following spine surgery.

Why it Occurs

There are many possible factors that could be the cause of pain in those diagnosed with Post-Laminectomy Syndrome. The decompression of the spinal nerve root during surgery may not fully recover, continuing to be the source of chronic nerve pain in the back and/or the legs (sciatica). Other times, scar tissue formed during the healing process may surround the nerves and cause pain. In some instances, the vertebrae adjacent to the surgical site may change structurally. Other causes include recurrent or new disc herniation, post-operative spinal or pelvic ligament instability (such as SI joint dysfunction), altered joint mobility, and spinal muscular deconditioning.

Symptoms

With Post-Laminectomy Syndrome, the desired outcomes of pain reduction or elimination are not fulfilled. The symptoms may be similar to the pain experienced before surgery. You may feel a dull and achy pain primarily located in the spinal column or a sharp and stabbing pain radiating down the legs, similar to sciatica. Abnormal sensitivity (hyperalgesia) to heat and pressure may also occur. The pain may range from mild to severe.

Treatment

A comprehensive treatment plan will be tailored to address the individual and specific diagnosis. Non-surgical treatment may be appropriate and can include physical therapy, spinal manipulation, anti-inflammatory medications (NSAIDS), spinal cord stimulation, and spinal injections. In some cases, revision surgery may be required to eliminate the pain.

Preventing Hip Fractures

Overview

A hip fracture is a serious injury, particularly if you’re older, and complications can be life-threatening. Most hip fractures occur in people older than 65, with the risk increasing most rapidly after age 80. Older people are at higher risk of hip fracture because bones tend to weaken with age. This bone weakening is called osteoporosis. Multiple medications, poor vision and balance problems also make older people more likely to trip and fall — one of the most common causes of hip fracture. A hip fracture almost always requires surgical repair or replacement, followed by months of physical therapy. Taking steps to maintain bone density and prevent falls can help prevent hip fracture.

Why it Occurs

A severe impact — in a car crash, for example — can cause hip fractures in people of all ages. In older adults, a hip fracture is most often a result of a fall from a standing height. In people with very weak bones, a hip fracture can occur simply by standing on the leg and twisting.

Risk Factors
A combination of factors may increase your risk of a hip fracture, including:
• Age. The rate of hip fractures increases substantially with age. As you age, your bone density and muscle mass both decrease. Older age may also bring vision and balance problems, along with slower reaction time to avoid falling when you feel unsteady. If you’re inactive, your muscles tend to weaken even more as you age. All of these factors combined can increase your risk of a hip fracture.
• Your sex. Women lose bone density at a faster rate than men do. The drop in estrogen levels that occurs with menopause accelerates bone loss, increasing the risk of hip fractures. However, men also can develop dangerously low levels of bone density.
• Chronic medical conditions. Osteoporosis is the most powerful risk factor for hip fracture, but other medical conditions may lead to fragile bones. These include endocrine disorders, such as an overactive thyroid, and intestinal disorders, which may reduce your absorption of vitamin D and calcium.
• Certain medications. Cortisone medications, such as prednisone, can weaken bone if you take them long term. In some cases, certain drugs or the combination of medications can make you dizzy and more prone to falling.
• Nutritional problems. Lack of calcium and vitamin D in your diet when you’re young lowers your peak bone mass and increases your risk of fracture later in life. Serious eating disorders, such as anorexia nervosa and bulimia, can damage your skeleton by depriving your body of essential nutrients needed for bone building.
• Physical inactivity. Weight-bearing exercises, such as walking, help strengthen bones and muscles, making falls and fractures less likely. If you don’t regularly participate in weight-bearing exercise, you may have lower bone density and weaker bones.
• Tobacco and alcohol use. Smoking and drinking alcohol can interfere with the normal processes of bone building and remodeling, resulting in bone loss.

Symptoms

Signs and symptoms of a hip fracture may include:
• Inability to move immediately after a fall
• Severe pain in your hip or groin
• Inability to put weight on your leg on the side of your injured hip
• Stiffness, bruising and swelling in and around your hip area
• Shorter leg on the side of your injured hip
• Turning outward of your leg on the side of your injured hip

Treatment

A hip fracture is a serious injury that can reduce your future independence and sometimes even shorten your life. Many adults who lived independently prior to their hip fracture are still in a nursing home more than a year after their injury. Treatment is usually with surgery and recovery may be prolonged in the elderly. Prevention and balance testing to screen for further testing as indicated may be helpful in at risk populations.
If a hip fracture keeps you immobile for a long time, you may develop one or more of the following complications:
• Blood clots in your legs or lungs
• Bedsores
• Urinary tract infection
• Pneumonia
Additionally, people who’ve had one hip fracture have a significantly increased risk of having another one.

Restless Leg Syndrome

Overview

Restless legs syndrome (RLS) is a condition in which your legs feel extremely uncomfortable, typically in the evenings while you’re sitting or lying down. It makes you feel like getting up and moving around. When you do so, the unpleasant feeling of restless legs syndrome temporarily goes away. Restless legs syndrome can begin at any age and generally worsens as you age. Restless legs syndrome can disrupt sleep — leading to daytime drowsiness — and make traveling difficult. A number of simple self-care steps and lifestyle changes may help you. Medications also help many people with restless legs syndrome.

Why it Occurs

In many cases, no known cause for restless legs syndrome exists. Researchers suspect the condition may be due to an imbalance of the brain chemical dopamine. This chemical sends messages to control muscle movement.
Heredity
RLS runs in families in at least half the people with RLS, especially if the condition started at an early age. Researchers have identified sites on the chromosomes where genes for RLS may be present.
Pregnancy
Pregnancy or hormonal changes may temporarily worsen RLS signs and symptoms. Some women experience RLS for the first time during pregnancy, especially during their last trimester. However, for most of these women, signs and symptoms usually disappear quickly after delivery.
Related conditions
For the most part, restless legs syndrome isn’t related to a serious underlying medical problem. However, RLS sometimes accompanies other conditions, such as:
• Peripheral neuropathy. This damage to the nerves in your hands and feet is sometimes due to chronic diseases such as diabetes and alcoholism.
• Iron deficiency. Even without anemia, iron deficiency can cause or worsen RLS. If you have a history of bleeding from your stomach or bowels, experience heavy menstrual periods, or repeatedly donate blood, you may have iron deficiency.
• Kidney failure. If you have kidney failure, you may also have iron deficiency, often with anemia. When kidneys fail to function properly, iron stores in your blood can decrease. This, with other changes in body chemistry, may cause or worsen RLS.

Symptoms

Commonly described sensations
People typically describe restless legs syndrome symptoms as abnormal, unpleasant sensations in their calves, thighs or feet. Sometimes the sensations may be in the arms, often expressed as: crawling, creeping, pulling, throbbing, Itching, pain, tugging, gnawing, and burning.
Sometimes the sensations seem to defy description. Affected people usually don’t describe the condition as a muscle cramp or numbness. They do, however, consistently describe the desire to move or handle their legs. It’s common for symptoms to fluctuate in severity, and occasionally symptoms disappear for periods of time.
Commonly reported patterns
Common characteristics of RLS signs and symptoms include:
• Onset during inactivity. The sensation typically begins after you’ve been lying down or sitting for an extended period of time, such as in a car, airplane or movie theater.
• Relief by movement. The sensation of RLS lessens if you get up and move. People combat the sensation of restless legs in a number of ways — by stretching, jiggling their legs, pacing the floor, exercising or walking. This compelling desire to move is what gives restless legs syndrome its name.
• Worsening of symptoms in the evening. Symptoms typically are less bothersome during the day and are felt primarily at night.
• Nighttime leg twitching. RLS may be associated with another condition called periodic limb movement disorder (PLMD). PLMD causes you to involuntarily flex and extend your legs while sleeping — without being aware you’re doing it. Hundreds of these twitching or kicking movements may occur throughout the night. If you have severe RLS, these involuntary kicking movements may also occur while you’re awake. PLMS is common in older adults, even without RLS, and doesn’t always disrupt sleep. More than 4 out of 5 people with RLS also experience PLMD.

Treatment

RLS can develop at any age, even during childhood. Many adults who have RLS can recall being told as a child that they had growing pains or can remember parents rubbing their legs to help them fall asleep. The disorder is more common with increasing age. Although RLS doesn’t lead to other serious conditions, symptoms can range from barely bothersome to incapacitating. Many people with RLS find it difficult to get to sleep or stay asleep. Insomnia may lead to excessive daytime drowsiness, but RLS may prevent you from enjoying a daytime nap. Medication to help with sleep and restless legs can be helpful in some cases. Spinal cord stimulation and neuromodulation can also help if the cause is related to peripheral neuropathy or PLMD.

Rotator Cuff Injuries

Overview

Your rotator cuff is made up of the muscles and tendons in your shoulder. These muscles and tendons connect your upper arm bone with your shoulder blade. They also help hold the ball of your upper arm bone firmly in your shoulder socket. The combination results in the greatest range of motion of any joint in your body. A rotator cuff injury includes any type of irritation or damage to your rotator cuff muscles or tendons. Causes of a rotator cuff injury may include falling, lifting and repetitive arm activities — especially those done overhead, such as throwing a baseball or placing items on overhead shelves. About half of the time, a rotator cuff injury can heal with self-care measures or exercise therapy.

Why it Occurs

Four major muscles (subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons connect your upper arm bone (humerus) with your shoulder blade (scapula). A rotator cuff injury, which is fairly common, involves any type of irritation or damage to your rotator cuff muscles or tendons, including:
• Tendinitis. Tendons in your rotator cuff can become inflamed due to overuse or overload, especially if you’re an athlete who performs a lot of overhead activities, such as in tennis or racquetball.
• Bursitis. The fluid-filled sac (bursa) between your shoulder joint and rotator cuff tendons can become irritated and inflamed.
• Strain or tear. Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.
Common causes of rotator cuff injuries include:
• Normal wear and tear. Increasingly after age 40, normal wear and tear on your rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff’s tendons and muscles. This makes them more prone to degeneration and injury. With age, you may also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate your rotator cuff.
• Poor posture. When you slouch your neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under your shoulder bones (including your collarbone), especially during overhead activities, such as throwing.
• Falling. Using your arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.
• Lifting or pulling. Lifting an object that’s too heavy or doing so improperly — especially overhead — can strain or tear your tendons or muscles. Likewise, pulling something, such as a high-poundage archery bow, may cause an injury.
• Repetitive stress. Repetitive overhead movement of your arms can stress your rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers, swimmers and tennis players. It’s also common among people in the building trades, such as painters and carpenters.

Symptoms

Rotator cuff injury signs and symptoms may include:
• Pain and tenderness in your shoulder, especially when reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side
• Shoulder weakness
• Loss of shoulder range of motion
• Inclination to keep your shoulder inactive
The most common symptom is pain. You may experience it when you reach up to comb your hair, bend your arm back to put on a jacket or carry something heavy. Lying on the affected shoulder also can be painful. If you have a severe injury, such as a large tear, you may experience continuous pain and muscle weakness.

Risk Factors
The following factors may increase your risk of having a rotator cuff injury:
• Age. As you get older, your risk of a rotator cuff injury increases. Rotator cuff tears are most common in people older than 40.
• Being an athlete. Athletes who regularly use repetitive motions, such as baseball pitchers, archers and tennis players, have a greater risk of having a rotator cuff injury.
• Working in the construction trades. Carpenters and painters, who also use repetitive motions, have an increased risk of injury.
• Having poor posture. A forward-shoulder posture can cause a muscle or tendon to become irritated and inflamed when you throw or perform overhead activities.
• Having weak shoulder muscles. This risk factor can be decreased or eliminated with shoulder-strengthening exercises, especially for the less commonly strengthened muscles on the back of the shoulder and around the shoulder blades.

Treatment

Conservative management and care can make your shoulder more comfortable by:
• Resting your shoulder. Avoid movements that aggravate your shoulder and give you more pain.
• Applying cold packs to reduce pain and inflammation.
• Taking pain medications, if necessary. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen (Aleve), may help reduce pain. Acetaminophen (Tylenol, others) also may help relieve pain.
Most of the time, treatment for rotator cuff injuries involves exercise therapy. Your doctor or a physical therapist will talk with you about specific exercises designed to help heal your injury, improve the flexibility of your rotator cuff and shoulder muscles, and provide balanced shoulder muscle strength. Depending on the severity of your injury, physical therapy may take from several weeks to several months to reach maximum effectiveness.
Other rotator cuff injury treatments may include:
• Steroid injections. Depending on the severity of your pain, your doctor may use a corticosteroid injection to relieve inflammation and pain.
• Surgery. If you have a large tear in your rotator cuff, you may need surgery to repair the tear. Sometimes during this kind of surgery doctors may remove a bone spur or calcium deposits. The surgery may be performed as an open repair through a 2 1/2- to 4-inch (6- to 10-centimeter) incision, as a mini-open repair through a 1 1/4- to 2-inch (3- to 5-centimeter) incision, or as an arthroscopic repair with the aid of a small camera inserted through a smaller incision.
• Arthroplasty. Some long-standing rotator cuff tears over time may contribute to the development of rotator cuff arthropathy, which can include severe arthritis. In such cases, your doctor may discuss with you more extensive surgical options, including partial shoulder replacement (hemiarthroplasty) or total shoulder replacement (prosthetic arthroplasty).

Scoliosis

Overview

Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown. Most cases of scoliosis are mild, but some children develop spine deformities that continue to get more severe as they grow. Severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly. Others may need surgery to keep the scoliosis from worsening and to straighten severe cases of scoliosis.

Why it Occurs

Doctors don’t know what causes the most common type of scoliosis — although it appears to involve hereditary factors, because the disorder tends to run in families. Less common types of scoliosis may be caused by:
• Neuromuscular conditions, such as cerebral palsy or muscular dystrophy
• Birth defects affecting the development of the bones of the spine
• Injuries to or infections of the spine

While most people with scoliosis have a mild form of the disorder, scoliosis may sometimes cause complications, including:
• Lung and heart damage. In severe scoliosis, the rib cage may press against the lungs and heart, making it more difficult to breathe and harder for the heart to pump.
• Back problems. Adults who had scoliosis as children are more likely to have chronic back pain than are people in the general population.
• Appearance. As scoliosis worsens, it can cause more noticeable changes — including unlevel shoulders, prominent ribs, uneven hips, and a shift of the waist and trunk to the side. Individuals with scoliosis often become self-conscious about their appearance.

Symptoms

Signs and symptoms of scoliosis may include:
• Uneven shoulders
• One shoulder blade that appears more prominent than the other
• Uneven waist
• One hip higher than the other
If a scoliosis curve gets worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side. Severe scoliosis can cause back pain and difficulty breathing.

Treatment

Scoliosis is often accompanied by slight twisting or rotation of the trunk. Scoliosis may go undetected because mild spinal curves aren’t immediately visible and the condition rarely causes pain in children. In many cases, treatment isn’t necessary, although regular follow-up is wise because spinal curves tend to worsen during periods of rapid growth. If the scoliosis causes dysfunction with breathing it may require a more aggressive treatment plan or even surgery. The two main treatments are bracing and surgery. A spinal brace slows the progression of mild- and moderate-sized growth-related curves. Surgery, which usually involves fusing some spinal bones (vertebrae) to hold them in alignment, is necessary for a severe curve to prevent continued worsening during adult life.

Shingles

Overview

Shingles is a viral infection that causes a painful rash. Although shingles can occur anywhere on your body, it most often appears as a single stripe of blisters that wraps around either the left or the right side of your torso. Shingles is caused by the varicella-zoster virus — the same virus that causes chickenpox. After you’ve had chickenpox, the virus lies inactive in nerve tissue near your spinal cord and brain. Years later, the virus may reactivate as shingles. While it isn’t a life-threatening condition, shingles can be very painful. Vaccines can help reduce the risk of shingles, while early treatment can help shorten a shingles infection and lessen the chance of complications.

Why it Occurs

Shingles is caused by the varicella-zoster virus — the same virus that causes chickenpox. Anyone who’s had chickenpox may develop shingles. After you recover from chickenpox, the virus can enter your nervous system and lie dormant for years. Eventually, it may reactivate and travel along nerve pathways to your skin — producing shingles. The reason for the encore is unclear. But it may be due to lowered immunity to infections as you grow older. Shingles is more common in older adults and in people who have weak immune systems.
Varicella-zoster is part of a group of viruses called herpes viruses, which includes the viruses that cause cold sores and genital herpes. Because of this, shingles is also known as herpes zoster. But the virus that causes chickenpox and shingles is not the same virus responsible for cold sores or genital herpes, a sexually transmitted infection.
Are you contagious?
A person with shingles can pass the varicella-zoster virus to anyone who isn’t immune to chickenpox. This usually occurs through direct contact with the open sores of the shingles rash. Once infected, the person will develop chickenpox, however, not shingles.
Chickenpox can be dangerous for some groups of people. Until your shingles blisters scab over, you are contagious and should avoid physical contact with: anyone who has a weak immune system, newborns and pregnant women.

Symptoms

The signs and symptoms of shingles usually affect only a small section of one side of your body. These signs and symptoms may include:
• Pain, burning, numbness or tingling
• A red rash that begins a few days after the pain
• Fluid-filled blisters that break open and crust over
• Itching

Some people also experience: fever and chills, general achiness, headache and fatigue.
Pain is usually the first symptom of shingles. For some, it can be intense. Depending on the location of the pain, it can sometimes be mistaken for a symptom of problems affecting the heart, lungs or kidneys. Some people experience shingles pain without ever developing the rash.
Most commonly, the shingles rash develops as a stripe of blisters that wraps around either the left or right side of your torso. Sometimes the shingles rash occurs around one eye or on one side of the neck or face.
When to see a doctor
Contact your doctor promptly if you suspect shingles, but especially in the following situations:
• The pain and rash occur near an eye. If left untreated, this infection can lead to permanent eye damage. This is a medical emergency and care should be sought at earliest time possible.
• You’re 65 or older, which increases your risk of complications.
• You or someone in your family has a weakened immune system (due to cancer, medications or chronic illness).
• The rash is widespread or painful.

Treatment

There’s no cure for shingles, but prompt treatment with prescription antiviral drugs can speed healing and reduce your risk of complications. These medications include:
• Acyclovir (Zovirax)
• Valacyclovir (Valtrex)
• Famciclovir (Famvir)
Shingles can cause severe pain, so your doctor may prescribe:
• Anticonvulsants, such as gabapentin (Neurontin)
• Tricyclic antidepressants, such as amitriptyline
• Numbing agents, such as lidocaine, delivered via a cream, gel, spray or skin patch
• Medications that contain narcotics, such as codeine

If the episode is done and the rash has cleared, there still may be chronic persistent pain in the affected nerve area. This can lead to chronic pain syndrome called post herpetic neuralgia. The treatment can be as above with medications or can include epidural corticosteroid injections if indicated. These may need to be repeated for hard to resolve cases.

Sleep Apnea

Overview

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly and you feel tired even after a full night’s sleep.
There are two main types of sleep apnea:
• Obstructive sleep apnea, the more common form that occurs when throat muscles relax
• Central sleep apnea, which occurs when your brain doesn’t send proper signals to the muscles that control breathing
Treatment is necessary to avoid heart problems and other complications.

Symptoms

People with cervical stenosis with myelopathy may note one or more of the following spinal stenosis symptoms:
• Heavy feeling in the legs
• Inability to walk at a brisk pace
• Deterioration in fine motor skills (such as handwriting or buttoning a shirt)
• Intermittent shooting pains into the arms and legs (like an electrical shock), especially when bending their head forward (known as Lermitte’s phenomenon)
• Arm pain (cervical radiculopathy).

Treatment

The only effective cervical stenosis treatment for myelopathy is surgical decompression of the spinal canal. If the patient also has a radiculopathy (myeloradiculopathy), conservative treatment like NSAIDS, activity modification and exercises for cervical stenosis may help relieve the arm pain. Cervical epidural corticosteroid injections may be helpful to relieve the swelling of nerves causing the pain and may help forgo surgery if indicated.
Myelopathy is a generally progressive condition that develops slowly. Cervical spinal stenosis symptoms with myelopathy may not progress for years, and then difficulties with coordination may suddenly increase. Unfortunately, the symptoms rarely improve without cervical stenosis surgery to decompress the affected area.

Tension Headaches

Overview

A tension headache is generally a diffuse, mild to moderate pain in your head that’s often described as feeling like a tight band around your head. A tension headache (tension-type headache) is the most common type of headache, and yet its causes aren’t well understood. Treatments for tension headaches are available. Managing a tension headache is often a balance between fostering healthy habits, finding effective nondrug treatments and using medications appropriately.

Why it Occurs

The cause of tension headache is not known. Experts used to think tension headaches stemmed from muscle contractions in the face, neck and scalp, perhaps as a result of heightened emotions, tension or stress. But research suggests muscle contractions aren’t the cause. The most common theories support a heightened sensitivity to pain in people who have tension headaches and possibly a heightened sensitivity to stress. Increased muscle tenderness, a common symptom of tension headache, may result from a sensitized pain system.
Triggers
Stress is the most commonly reported trigger for tension headaches.
Risk Factors
Risk factors for tension headache include:
• Being a woman. One study found that almost 90 percent of women and about 70 percent of men experience tension headaches during their lifetimes.
• Being middle-aged. The incidence of tension headaches appears to peak in the 40s, though people of all ages can get this type of headache.

Symptoms

Signs and symptoms of a tension headache include:
• Dull, aching head pain
• Sensation of tightness or pressure across your forehead or on the sides and back of your head
• Tenderness on your scalp, neck and shoulder muscles
Tension headaches are divided into two main categories — episodic and chronic.
Episodic tension headaches
Episodic tension headaches can last from 30 minutes to a week. Frequent episodic tension headaches occur less than 15 days a month for at least three months. Frequent episodic tension headaches may become chronic.
Chronic tension headaches
This type of tension headache lasts hours and may be continuous. If your headaches occur 15 or more days a month for at least three months, they’re considered chronic.
Tension headaches vs. migraines
Tension headaches can be difficult to distinguish from migraines. Plus, if you have frequent episodic tension headaches, you can also have migraines.
Unlike some forms of migraine, tension headache usually isn’t associated with visual disturbances, nausea or vomiting. Although physical activity typically aggravates migraine pain, it doesn’t make tension headache pain worse. An increased sensitivity to either light or sound can occur with a tension headache, but these aren’t common symptoms.
Even if you have a history of headaches, see your doctor if the pattern changes or your headaches suddenly feel different. Occasionally, headaches may indicate a serious medical condition, such as a brain tumor or rupture of a weakened blood vessel (aneurysm).
When to seek emergency help
If you have any of these signs or symptoms, seek emergency care:
• Abrupt, severe headache
• Headache with a fever, stiff neck, mental confusion, seizures, double vision, weakness, numbness or speaking difficulties
• Headache after a head injury, especially if the headache gets worse

Treatment

Treatment can be helped with a complete history of the headache type, pattern, and any changes. This can be helped by keeping a “Headache Diary” somewhat like the following:

Keep a headache diary. To gather information about your headaches that will help your doctor, keep a headache diary. For each headache, jot down:
• Date. Charting the date and time of each headache can help you recognize patterns.
• Duration. How long did your headache last?
• Intensity. Rate your headache pain on a scale from 1 to 10, with 10 being the worst.
• Triggers. List possible triggers of your headache, such as certain foods, physical activities, noise, stress, smoke, bright lights or changes in weather.
• Symptoms. Did you have symptoms before you got the headache?
• Medications. What medications have you taken? List any, including dosage, even if they’re unrelated to your headache.
• Relief. Have you experienced any pain relief and from what?

Other treatment plans can include the following:

Some people with tension headaches don’t seek medical attention and try to treat the pain on their own. Unfortunately, repeated use of over-the-counter (OTC) pain relievers can actually cause overuse headaches. A variety of medications, both OTC and prescription, are available to reduce the pain of a headache, including:
• Pain relievers. Simple OTC pain relievers are usually the first line of treatment for reducing headache pain. These include the drugs aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve). Prescription medications include naproxen (Naprosyn), indomethacin (Indocin) and ketorolac (Ketorolac Tromethamine).
• Combination medications. Aspirin or acetaminophen or both are often combined with caffeine or a sedative drug in a single medication. Combination drugs may be more effective than are single-ingredient pain relievers. Many combination drugs are available OTC.
• Triptans and narcotics. For people who experience both migraines and episodic tension headaches, a triptan can effectively relieve the pain of both headaches. Opiates, or narcotics, are rarely used because of their side effects and potential for dependency.
Preventive medications
Your doctor may prescribe medications to reduce the frequency and severity of attacks, especially if you have frequent or chronic headaches that aren’t relieved by pain medication and other therapies.
Preventive medications may include:
• Tricyclic antidepressants. Tricyclic antidepressants, including amitriptyline and nortriptyline (Pamelor), are the most commonly used medications to prevent tension headache. Side effects of these medications may include weight gain, drowsiness and dry mouth.
• Other antidepressants. There also is some evidence to support the use of the antidepressants venlafaxine (Effexor XR) and mirtazapine (Remeron) in people who don’t also have depression.
• Anticonvulsants and muscle relaxants. Other medications that may prevent tension headache include anticonvulsants, such as topiramate (Topamax).
Preventive medications may require several weeks or more to build up in your system before they take effect. So don’t get frustrated if you haven’t seen improvements shortly after you begin taking the drug.

Where Back Pain Begins

Overview

Back pain can start at the vertebral disc level which serve as the spinal column’s shock absorbers. They cushion the vertebral bones and allow the spine to twist and bend. They have two main components either of which may crack or tear and leak fluid or a bulging disc material onto the nerve roots. This can be from aging, traumatic injury or stress of rapid motion.

Why it Occurs

This pain can occur in the back and neck area from weakness in the vertebral discs from damaged wear and tear of aging or traumatic injury. Hard work, repeated motion and overuse injury can lead to this weakness in the outer fibers of the disc wall. Radial tears form in and around the sensitive nerve fibers in the disc wall and can lead to ‘disco-genic’ back pain. If the discs soft nucleus pushes through to the outer edge of the disc wall it can cause local back pain at the disc level.

Symptoms

When the disc ruptures or the inner nucleus pulposis bulgs or herniates through the tough outer wall of the disc in can compress the nerve or the nerve root. This can lead to pain, tingling, numbness or weakness in the distribution of the nerve level affected. This can be the cause of the radicular pain in one leg or arm, or both can be affected as well.

Treatment

Treatment for the onset of back pain in usually conservative as the pain can resolve on its own over the course of several days to weeks. If it last longer and becomes a more chronic pain situation then over the counter medications such as NSAID can be helpful. More advance therapy including stronger medications or corticosteroids, either by mouth or epidural injection can decrease swelling of the nerve root and relieve pain.

The patient can expect to have the procedure done while gaining access to the back. Usually this is done while lying face down and having fluoroscopic guidance for the placement of the needle into the central epidural space from the caudal canal located near the top of the buttock. Local anesthesia to numb the skin and injection of steroid are usually done as an outpatient or office procedure without sedation needed.

Outcomes

The procedure may take several days to get enough of the nerve swelling down in order to understand how the pain relief will take effect. The pain relief can last for several weeks to months or even longer. If the area is reinjured or the nerve is impinged again, the pain may recur and the procedure can be repeated as indicated.

Cervical Epidural Steroid Injection

Overview

Indications

This procedure is indicated for radicular type pain coming from ‘pinched’ nerves in the spine. Cervical radiculopathy, cervical stenosis, spondylosis with myelopathy, neck injury, HNP or herniated disc of the cervical spine, nerve root injury of the cervical spine, or other conditions that would cause nerve or nerve root swelling in the cervical spine are all well suited for treatment with this procedure.

What to Expect

The patient can expect to have the procedure done while gaining access to the back of the neck. Usually this is done while lying face down and having fluoroscopic guidance for the placement of the needle into the central epidural space. Mostly this is done in the midline of the intralaminal space, the middle of the neck below the spinous processes you feel in the back of your neck. Local anesthesia to numb the skin and injection of steroid are usually done as an outpatient or office procedure without sedation needed.

Outcomes

Cervical Facet Radiofrequency Neurotomy

Overview

This minimally-invasive pain management procedure, also called radiofrequency (RF) rhizotomy, reduces or eliminates the pain of damaged facet joints by disrupting the medial branch nerves that carry the pain signals to the brain. It is performed using local anesthetic to reduce pain.

Indications

Conditions that are well suited for this treatment are the same ones that can be treated by cervical medial branch nerve blocks. These include neck pain that is non radicular, motion sensitive, or associative with facet joint types of pain sources. Cervicalgia, degenerative joint pain, spondylosis, neck injury and some whiplash injuries are all treated with medial branch blocks and facet radiofrequency rhyzitomy if indicated.

This procedure is usually indicated for a more long lasting effect of pain relief after a prior medial branch block has shown effective relief. The same nerves are then indicated for the rhyziotomy procedure in order to prolong the pain relief. The area ‘burned’ is usually around 10 mm and the nerve can grow back with pain recurring after a prolonged period of pain relief.

What to Expect

1. Cannula Inserted – A needle like tube called a cannula is inserted and positioned near the irritated medial branch nerves. Fluoroscopic x-ray is used to help position the cannula properly.
2. Electrode Inserted – A radiofrequency electrode is inserted through the cannula. The physician tests the electrode’s position by administering a weak electric jolt. If the stimulation recreates the pain without any other muscular effects, the electrode is positioned correctly.
3. Nerve Treated – The physician uses the electrode to heat and cauterize the nerve. This disrupts its ability to communicate with the brain, blocking the pain signals. The physician may treat multiple nerves if needed.

Outcomes

Chiropractic

Overview

Although a wide diversity of ideas currently exists among chiropractors they share the belief that the spine and health are related in a fundamental way, and that this relationship is mediated through the nervous system. Chiropractors examine the biomechanics, structure and function of the spine, along with its effects on the musculoskeletal and nervous systems and what they believe to be its role in health and disease.

Indications

A holistic approach to health and the spine is the basis for why most people seek chiropractic care. The main reason people seek out chiropractor care is low back pain. Muscular pain of the spine, hip and back issues can be well treated with the manipulation and adjustments based on chiropractic principles. It is an adjunctive therapy to a healthy lifestyle and pain program and can be used to help with many different conditions causing pain of the spine and muscular system.

What to Expect

You can expect to be referred to a chiropractor as indicated for the treatment of spinal or muscular type pain. They should do a history, exam and give you a care plan for treatment. Most insurance will cover some chiropractic care but not all chiropractors will accept payment, such that most patients should expect to pay for each session. It may take multiple visits to achieve the desired results and it may take additional sessions over time to maintain the holistic state of health desired.

Outcomes

Chiropractic therapy has achieved good results in many different conditions and is used as an adjunctive therapy commonly for low back painful conditions. Like most therapy, it may need to be repeated in order to achieve the expected results along with other pain management therapy and holistic therapy used for a total pain management.

Deep Brain Stimulation (DBS)

Overview

Deep brain stimulation involves implanting electrodes within certain areas of your brain. These electrodes produce electrical impulses that regulate abnormal impulses. Or, the electrical impulses can affect certain cells and chemicals within the brain. The amount of stimulation in deep brain stimulation is controlled by a pacemaker-like device placed under the skin in your upper chest. A wire that travels under your skin connects this device to the electrodes in your brain.

Indications

Deep brain stimulation is used to treat a number of neurological conditions, such as:
• Essential tremor
• Parkinson’s disease
• Dystonia

Deep brain stimulation is also being studied as an experimental treatment for epilepsy, cluster headaches, Tourette syndrome, chronic pain and major depression. Many candidates for deep brain stimulation are participants in clinical trials. Most patients will need to be referred to a center that does this procedure on a regular basis and has experience in treating the types of conditions that can benefit from the therapy.

What to Expect

Deep brain stimulation is an established treatment for movement disorders, such as essential tremor, Parkinson’s disease, and dystonia, and more recently, obsessive-compulsive disorder. This treatment is usually reserved for people who aren’t able to get control of their symptoms with medications.
After proper evaluation and referral for consideration of the therapy, if you undergo the procedure for deep brain stimulation your doctor will provide you details of the procedure. In short, you are fitted with a devise for the surgery to enable the surgeon to find with precision the target area and after access is gained with local anesthesia through the skull, the patient is able to respond to the stimulation once the leads are properly placed. The effects can be immediate as to movement and control issues.

Outcomes

With proper patient selection, psychological evaluation and trail the outcome of Deep Brain Stimulation can be life changing for patients with otherwise severe disability due to the indicated conditions. A permanent solution to the problem with the control of movement and/or tremor man mean a return to a more functional and satisfactory lifestyle.

Facet Joint Injections

Overview

The purpose of facet joint injection is to ‘numb’ suspected facet joints that are causing painful conditions. In this way the blockade will reduce or eliminates the pain of damaged facet joints by blocking the painful joint that carries the pain signals to the brain. It is performed using local anesthetic to reduce pain with anti-inflammatory steroid added if inflammation of the joint is also a contributing factor. The procedure is very similar to the medical branch block but with a different target of the actual facet joint, rather than the nerve to the joint.

Indications

Conditions that are well suited for this treatment are the same ones that can be treated by cervical/lumbar medial branch nerve blocks and rhizotomy. These include neck or back pain that is non radicular, motion sensitive, or associative with facet joint types of pain sources. Cervicalgia, lumbago, degenerative joint pain, spondylosis, neck or back injury and some whiplash injuries are all treated with medial branch blocks and later facet radiofrequency rhyzitomy if indicated.
This procedure is usually indicated for mostly non radicular pain. This can include facet arthropathy, facet joint or disc degeneration and the facet joint syndrome. The same joint is then indicated for the rhyziotomy procedure in order to prolong the pain relief. The area ‘burned’ is usually around 10 mm and the nerve can grow back with pain recurring after a prolonged period of pain relief.

What to Expect

Patients usually have injections of the facet joint done on an outpatient basis using fluoroscopy or other image guidance for proper needle placement. The skin will be numbed and the needles placed with sometimes small amounts of contrast used to confirm placement. Then a solution of steroid and/or local anesthetic is injected in small amounts. The effects of the local anesthetic will wear off before the steroid takes full effect such that the immediate effects of the anesthesia may wear off and the pain recur prior to the longer lasting effect of the steroid.

Outcomes

Although pain may increase for the first week after the procedure, the patient usually has full relief from pain within a month. Successful radiofrequency neurotomies can last longer than steroid block with local anesthesia injections. Medial branch nerve blocks are usually done to both treat and diagnosis the cause and effect of the suspected pain condition. For a return of the pain the blocks can be repeated or a rhizotomy can be done on the same nerves.

Fluoroscopic Guided Piriformis Injection

Overview

Piriformis muscle syndrome can mimic pain like sciatica, or the large nerve pain that produces sharp shooting pain down the leg. Piriformis muscle syndrome pain starts in the lower back and/or buttocks, sometimes feeling as if it’s deep inside the buttock muscles. It may be too painful to sit on the affected buttock. The pain and/or tingling can radiate down the backs of the legs as well.

Indications

The piriformis muscle runs behind the hip joint and aids in external hip rotation, or turning your leg outward. The catch here is that the piriformis crosses over the sciatic nerve. The piriformis muscle can become tight from, for example, too much sitting (a problem many working people can relate to). The muscle can also be strained by spasm or overuse. In piriformis syndrome, this tightness or spasm causes the muscle to compress and irritate the sciatic nerve. This brings on lower-back and buttock pain, sometimes severe. The diagnosis is tricky because piriformis syndrome can very easily be confused with sciatica.

The difference between these diagnoses is that traditional sciatica is generally caused by some spinal issue, like a compressed lumbar disc. Piriformis syndrome becomes the go-to diagnosis when sciatica is present with no discernible spinal cause. Runners, cyclists and rowers are the athletes most at risk for piriformis syndrome. Other people that are risk are anyone who over pronates the foot in their gait. It can also be seen after treatment for spinal stenosis and/or neurogenic claudication with the mild® procedure as the once leaning forward walking motion is replaced with a straighter, more upright gait, thereby staining the sciatic nerve with the piriformis muscle.

What to Expect

Treatment of the syndrome is easy and straight forward. It is done on an outpatient basis usually in the office using fluoroscopy (x-ray) or ultrasound guidance. Proper placement of a single needle to the depth of the piriformis muscle, located deep to the gluteus Maximus and Minimus muscles in the buttock area is why imaging guidance is needed. Once access to the buttock area is obtained, the skin is prepped and skin numbed with the needle placed by way of imaging confirmation. Contrast may be used to ensure proper placement. Injection of local anesthetic to help relief of the pain and spasm (trigger point) of the piriformis muscle with steroid for the inflammation is undertaken and the spread noted via imaging. A band aid is used for dressing and physical therapy, home stretching and exercises are given.

Outcomes

Many patients note immediate relief after this injection. Outcomes for this procedure are excellent and usually only one or two injections, along with home therapy and exercises are all that are needed for prolonged relief. The spasm and sciatica type pain may recur and if not relieved by conservative management the injection can be repeated. Many mild® procedure patients note that after this injection they can now fully understand the benefit from the mild® procedure and the gait changes that is has produced, enabling them to walk straighter, longer, and with less pain now that the piriformis muscle syndrome has been treated.

Intracapsular (Glenoid) Injection

Overview

Intracapsular glenoid injection is a procedure in which anesthetic and anti-inflammatory steroid medication is injected as a mixture between the glenoid and the head of the humerus. This is done for shoulder pain and discomfort that has not responded to conservative management. Frozen shoulder is a common complaint that can respond to this injection. The injection is done with ultra sound guidance to insure proper placement of the needle.

Indications

Several painful conditions may be treated with this procedure, including rheumatoid arthritis and osteoarthritis in the shoulder joint. Adhesive capsulitis, commonly known as “Frozen Shoulder,” may also benefit from intracapsular glenoid injections. Often this this treatment is used if other more conservative methods, like physical therapy, have already been attempted. However, injections may also be used in conjunction with other conservative treatments in order to help with physical therapy and range of motion exercised. The effects of the injection may wear off and need to be repeated.

What to Expect

The procedure is easy and with ultra sound guidance the patient can be assured that the successful placement of the needle is greatest vs other so called ‘blind’ injections. The skin is prepped and the area numbed. A small needle is used to enter the capsule of the joint under direct vision with the ultra sound guidance procedure. Once placed the injection of the solution of steroid and/or local anesthesia is done. A small band aid is placed. Many patients can get quick onset of relief and some may then go to physical therapy with the shoulder pain relief in place.

Outcomes

The prevention of the frozen shoulder syndrome is the ultimate outcome for this procedure. If a patent develops a frozen shoulder they may lose the ability for proper function of the affected sides hand and arm. Pain control and restoration of shoulder function is the intended outcome. The pain control is achieved and used as an adjunctive therapy with physical therapy, topical creams or applications, and home exercises. The effects of the injection may wear off and the injection may need to be repeated.

Intrathecal Pump Implant

Overview

An intrathecal pump, or ‘pain pump’, is a medical device used to deliver medications directly into the space between the spinal cord and the protective sheath surrounding the spinal cord. Medications such as baclofen, morphine, or other medication combinations may be delivered in this manner to minimize the side effects often associated with the higher doses used in oral or intravenous delivery of these drugs. It is used first on a trial basis and after a successful trial is determined, and then a permanent implant is undertaken and maintained with refilling of the pain needed on a regular basis.

Indications

There can be multiple indications for inthecal pump, or ‘pain pump’, implant after a successful trial. These can include the treatment of chronic pain after failed back surgery, sometimes called FBS or post laminectomy syndrome, non-radicular back pain that does not go below the hip area, cancer pain, or response to narcotic therapy traditionally that has now has produced tolerance or side effects.

What to Expect

After a successful trial of narcotics, usually morphine at low dose, by way of a small catheter and trialed over several days the implant will be undertaken. The procedure is done as an outpatient with local and IV sedation with the catheter place again in a similar fashion and now connected to a pump reservoir that is usually placed in the abdomen, buttock area or other choice of access position. You will go home the same day usually and the pump will have been filled and programmed accordingly. Infection precautions will be given and usually antibiotics maintained for a brief period of time.

Outcomes

Outcomes and long term results of placement for interthecal pain pumps using single drug low dose morphine are well documented as effective in the treatment for chronic pain. Infection and mechanical dislodgement of the catheter are the main concerns. Refill and maintenance of the pump with possible battery replacement after prolonged use are longer term maintenance issues.

Lumbar Epidural Steroid Injection

Overview

Indications

This procedure is indicated for radicular type pain coming from ‘pinched’ nerves in the spine. The lumbar approach is best used for lumbar or sacral nerves. It also is good for patients with leg pain that have had no responsive to a conservative management approach. Lumbar radiculopathy, lumbar stenosis, spondylosis with myelopathy, back injury, lumbar degenerative disc disease, HNP or herniated disc of the lumbar spine, nerve root injury of the lumbar or sacral spine, coccyx pain or other lumbar/pelvic conditions that would cause nerve or nerve root swelling in the lower spine are all well suited for treatment with this procedure.

What to Expect

The patient can expect to have the procedure done while gaining access to the back. Usually this is done while lying face down and having fluoroscopic guidance for the placement of the needle into the central epidural space from the canal located near the central area just below the lamina. Local anesthesia to numb the skin and injection of steroid are usually done as an outpatient or office procedure without sedation needed.

Outcomes

Lumbar Sympathetic Block

Overview

This injection can both diagnose and treat pain coming from the sympathetic nerves. It is a common treatment for shingles and complex regional pain syndromes affecting the lower back and legs, feet and joints of the lower extremities, and help increase blood flow to the lower extremities’ due to neuropathy. Usually a series of these injections is needed to treat the problem.

Indications

This procedure is indicated for use with pain conditions caused from complex regional pain syndromes of the lower extremity, peripheral neuropathy, RSD of the lower extremity, pelvic type pain, shingles in the mid thoracic, lumbar and lower extremity region, and some sympathetic nerve mediated pain syndromes of the thoracic and lumbar areas area. For sympathetic pain from the pelvic area, the lower ganglion may need to be blocked in the L5 and sacral areas or even in the coccyx area.

What to Expect

The patient will be face down under the fluoroscopy (x-ray) with a cushion under their abdomen in order to arch the back in a ‘mad cat’ type of position. This brings the lower lumbar ganglion area closer to the surface. The operator will feel and identify the muscles of the lumbar spine after injection local of anesthesia in the skin to numb the area first. Using the x-ray guidance, a needle will be placed through the numb skin and down to the lumbar ganglion on the anterior surface of the bone. Contrast can be used to identify proper placement and then injection of local long lasting anesthetic and steroid medications can be done in small intermittent doses while keeping contact with the patient.

Outcomes

Some patients get immediate relief of the pain and most will experience a change over time for a longer lasting relief and return to less painful state. Warmth increase in a cold extremity can be seen as well. The reflex of pain producing decreased blood flow can be broken with repeated blocks. The pain may recur in hopefully a lower intensity level and the injection may need to be repeated in a series of injections. The procedure can be used to both diagnosis and treat peripheral neuropathy and it may also be used to indicate if the patient is a candidate for a lumbar spinal cord stimulator trial.

Lumbar Transforaminal Epidural Steroid Injection

Overview

Indications

This procedure is indicated for radicular type pain coming from ‘pinched’ nerves in the spine. The lumbar approach is best used for lumbar or sacral nerves. It also is good for patients with leg pain that have had no responsive to a conservative management approach. If there is lumbar back surgery this approach is sometimes helpful to target specific nerves and/or avoid scar tissue from the surgery. Lumbar radiculopathy, lumbar stenosis, spondylosis with myelopathy, back injury, HNP or herniated disc of the lumbar spine, nerve root injury of the lumbar or sacral spine, coccyx pain or other lumbar/pelvic conditions that would cause nerve or nerve root swelling in the lower spine are all well suited for treatment with this procedure.

What to Expect

The patient can expect to have the procedure done while gaining access to the back. Usually this is done while lying face down and having fluoroscopic guidance for the placement of the needle into the central epidural space from the canal located near the central area below the spinal lamina. Local anesthesia to numb the skin and injection of steroid are usually done as an outpatient or office procedure without sedation needed.

Outcomes

Medial Branch Block

Overview

The purpose of medial branch blocks is to ‘numb’ suspected facet joints that are causing painful conditions. In this way the blockade will reduce or eliminates the pain of damaged facet joints by disrupting the medial branch nerves that carry the pain signals to the brain. It is performed using local anesthetic to reduce pain with anti-inflammatory steroid added if inflammation of the joint is also a contributing factor.

Indications

Conditions that are well suited for this treatment are the same ones that can be treated by cervical/lumbar medial branch nerve rhizotomy. These include neck or back pain that is non radicular, motion sensitive, or associative with facet joint types of pain sources. Cervicalgia, lumbago, degenerative joint pain, spondylosis, neck or back injury and some whiplash injuries are all treated with medial branch blocks and later facet radiofrequency rhyzitomy if indicated.
This procedure is usually indicated for mostly non radicular pain. Medial branch nerves are involved in pain coming from the facet joint. This can include facet arthropathy, facet joint or disc degeneration and the facet joint syndrome. The same nerves are then indicated for the rhyziotomy procedure in order to prolong the pain relief. The area ‘burned’ is usually around 10 mm and the nerve can grow back with pain recurring after a prolonged period of pain relief.

What to Expect

Patients usually have injections of the medial branch nerves done on an outpatient basis using fluoroscopy or other image guidance for proper needle placement. Because the nerves give off branches both above and below the joint, there usually are three or four needles used to block all the contributing nerves of the suspected levels. The skin will be numbed and the needles placed with sometimes small amounts of contrast used to confirm placement. Then a solution of steroid and/or local anesthetic is injected in small amounts. The effects of the local anesthetic will wear off before the steroid takes full effect such that the immediate effects of the anesthesia may wear off and the pain recur prior to the longer lasting effect of the steroid.

Outcomes

Pain Management

Overview

There are many individual and changing ways to treat pain. Each patient has different objectives and outcome expectations and finding a clinic that can help can be important in achieving the desired outcome. Commonwealth Pain Physicians use medications, minimally invasive techniques and procedures as well as blocks and injections to facilitate treatment based on objective diagnostic criteria in order to develop a plan of care. We call this individual plan of care the Pain—Personalized Care Plan or P—PCP™.

What to Expect

The injection site is numbed using a local anesthetic. One or more insulated wire leads are inserted through an epidural needle or through a needle into the space surrounding the spinal cord, called the epidural space. Electrodes at the end of the lead produce electrical pulses that stimulate the nerves, blocking pain signals to the brain. The patient gives feedback to help the physician determine where to place to place the stimulators to best block the patient’s pain. The lead is connected to an external trial stimulator, which will be used for three to seven days to determine if Spinal Cord Stimulation will help the patient. If the patient and physician determine that the amount of pain relief is acceptable, the system may be permanently implanted. At the end of the trial implantation, the lead is removed.

Permanent Implantation
The permanent implantation may be performed while the patient is under sedation or general anesthesia. First, one or more leads are inserted into the predetermined location in the epidural space. Next, a small incision is created, and the implantable pulse generator (IPG) battery is positioned beneath the skin. Most often, it is implanted in the buttocks, back or abdomen. The lead is then connected to the IPG battery. The implant’s electrical pulses are programmed with an external control unit. The patient can use the external control unit (remote) to turn the system on or off and adjust the stimulation power level and switch between different programs. After surgery, patients may experience mild discomfort and swelling at the incision sites for several days.

Outcomes

With proper patient selection, psychological screening for contraindications and careful use of proper lead placement to cover the painful area as much as possible at the trial phase the outcome of spinal cord stimulation can be a life changer. It can cause the pain to be controllable for the patient with programing available for different pain throughout the day if indicated. The goal is activity and functional improvement to reasonable levels determined in the initial patient evaluation process.

Spinal Chord Stimulator Implant (Trial Procedure)

Overview

Indications

The injection site is numbed using a local anesthetic. One or more insulated wire leads are inserted through an epidural needle or through a needle into the space surrounding the spinal cord, called the epidural space. Electrodes at the end of the lead produce electrical pulses that stimulate the nerves, blocking pain signals to the brain. The patient gives feedback to help the physician determine where to place the stimulators to best block the patient’s pain. The lead is connected to an external trial stimulator, which will be used for three to seven days to determine if Spinal Cord Stimulation will help the patient. If the patient and physician determine that the amount of pain relief is acceptable, the system may be permanently implanted. At the end of the trial implantation, the leads are removed.

What to Expect

The trail implant will be done as an outpatient basis with fluoroscopic (x-ray) guidance with local anesthesia and lite sedation. The patient needs to tell the operator if the sensations from the stimulation pattern are covering the painful area and adjustment may need to be made for the final position/placement of the leads. The trial will last for 3-10 days with contact made with the patient during this time period. Once the trial is over the leads are simply removed and a decision will be made regarding a permanent implant. If a permanent implant is done a similar pattern of stimulation using the leads and a stimulation generator, or IPG, will attempted. All components will be self-contained and under the skin in such a way as to be controlled by way of a small remote.

Outcomes

With proper patient selection, psychological screening for contraindications and careful use of proper lead placement to cover the painful area as much as possible at the trial phase the outcome of spinal cord stimulation can be a life changer. It can cause the pain to be controllable for the patient with programing available for different pain patterns throughout the day if indicated. The goal is activity and functional improvement to reasonable levels determined in the initial patient evaluation process.

Stellate Ganglion Block

Overview

This injection can both diagnose and treat pain coming from the sympathetic nerves. It is a common treatment for shingles and complex regional pain syndromes affecting the head, face, neck, and arms. It can help treat and increase pain control of low blood flow states caused by neuropathy of the upper extremities. Usually a series of these injections is needed to treat the problem.

Indications

This procedure is indicated for use with pain conditions caused from complex regional pain syndromes of the upper extremity, peripheral neuropathy, RSD of the upper extremity, facial pain, shingles in the head, face neck and shoulder region, and some sympathetic nerve mediated pain syndromes of the thoracic area.

What to Expect

The patient will be face up under the fluoroscopy (xray) with a cushion under their shoulders in order to arch the neck in ‘hanging head over the edge’ type of position. This brings the lower stellate ganglion area closer to the surface. The operator will feel and pull the muscles out of the way after injection local anesthesia in the skin to numb the area first. Using the x-ray guidance, a needle will be placed through the numb skin and down to the stellate ganglion of the upper surface of the bone. Contrast can be used to identify proper placement and then injection of local long lasting anesthetic and steroid medications can be done in small intermittent doses while keeping contact with the patient.

Outcomes

Some patients get immediate relief of the pain and most will experience a change over time for a longer lasting relief and return to less painful state. Warmth increase in a cold extremity can be seen as well. The reflex of pain producing decreased blood flow can be broken with repeated blocks. The pain may recur in hopefully a lower level and the injection may need to be repeated in a seris of injecitons. The procedure can be used to both diagnosis and treat peripheral neuropathy and it may also be used to indicate if the patient is a candidate for a cervical spinal cord stimulator trial.

Thoracic Epidural Steroid Injection

Overview

Indications

This procedure is indicated for radicular type pain coming from ‘pinched’ nerves in the spine. The thoracic approach is best used for lower thoracic or high to mid-lumbar nerves. It also is good for patients with leg pain that have had no responsive to a conservative management approach. It is often used to treat post herpetic neuralgia from shingles or ‘zoster’. Thoracic or Lumbar radiculopathy, lumbar stenosis, spondylosis with myelopathy, back injury, HNP or herniated disc of the thoracic or lumbar spine, nerve root injury of the lumbar or sacral spine or other lumbar/pelvic conditions that would cause nerve or nerve root swelling in the spine are all well suited for treatment with this procedure.

What to Expect

The patient can expect to have the procedure done while gaining access to the back. Usually this is done while lying face down and having fluoroscopic guidance for the placement of the needle into the central epidural space at the indicated level. Local anesthesia to numb the skin and injection of steroid are usually done as an outpatient or office procedure without sedation needed.

Outcomes

Trigger Point Injections

Overview