BELLEVUE SPINE SPECIALIST
 
13033 Bel Red Rd Suite 120, Bellevue, WA 98005 Phone: (425) 452-0101
Fax: (425) 452-0303
 










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Procedures

EPIDURAL STEROID INJECTION

Overview:

Epidural Steroid Injection (ESI) is an non-surgical treatment that may alleviate neck/back and arm/leg pain caused by conditions such as spinal stenosis, disc herniation and degenerative disc disease.

Medicines are delivered into the epidural space which lies between the protective covering of the spinal cord (dura mater) and the bony vertebral wall.

The goal is to reduce pain by diminishing inflammation of the spinal nerves so you may improve your daily function and continue with your rehabilitative exercises.

Procedure:

After an initial consultation with Dr. Chang and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned prone on the fluoroscopic table. You can either remain awake during the procedure or intravenous sedation may be administered to lessen anxiety. The target site is cleansed with antiseptic solution and sterilely draped. The skin over the injection site is numbed with a local anesthetic. A thin needle is then inserted into the epidural space under X-ray guidance. Once needle placement is confirmed with contrast medium, (figure 1), combination of a long-lasting steroid (triamcinolone) and a local anesthetic (bupivicaine/lidocaine) are deposited into the epidural space . The whole process takes approximately twenty to thirty minutes.

Post Procedure:

Most patients are able to leave the clinic upon completion of the procedure. Be aware of potential numbness and weakness of your legs/arms and avoid strenuous activities over the next 24 to 48 hours. Application of ice and oral intake of mild analgesics usually will alleviate potential soreness over the injection site although flair-ups are possible. Potential side effects from steroid administration may include transient flushing, restlessness and elevation of blood sugar. You should follow up with your referring physician's office in 10 to 14 days and report overall treatment response. There are no consensus in the medical community regarding the frequency of epidural steroid injections, the most prudent recommendation suggests evaluation of each and every injection prior to further treatments are planned.



SELECTIVE NERVE ROOT BLOCK

Overview

A selective nerve root block (SNRB) is primarily used as a diagnostic tool to determine if a specific spinal nerve root is the cause of your pain.

When a spinal nerve becomes inflamed or irritated due to disc herniation, bone spur formation or spinal stenosis, it can cause significant arm(s) or leg(s) pain.

By depositing a local anesthetic adjacent to the targeted nerve root and interrupt the transmission of pain signal, it will help isolate the nerve of interest.

Procedure

After an initial consultation with Dr. Chang and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned on the fluoroscopic table. You can either remain awake during the procedure or intravenous sedation may be administered to lessen anxiety. The target site is cleansed with antiseptic solution and sterilely draped. The skin over the injection site is numbed with a local anesthetic. A thin needle is then inserted into the neural foramen (the hole where the nerve root exit out of the spinal canal) under X-ray guidance. Once needle placement is confirmed with contrast medium, (figure 2), a local anesthetic (bupivicaine) and/or steroid (dexamethasone) is then deposited. The whole process takes approximately twenty to thirty minutes.

Post Procedure:

Most patients are able to leave the clinic upon completion of the procedure. Be aware of potential numbness and weakness of your arm or leg and avoid strenuous activities over the next 24 to 48 hours. The goal of most SNRB is to isolate the source of your pain. A pain questionnaire will need to be filled out over the next several hours to document treatment response. If your pain goes away after the injection, it can be inferred that the targeted nerve root is your pain generator. Application of ice usually will alleviate potential soreness over the injection site although flair-ups are possible. Please refrain from oral intake of pain medications until the questionnaire is completed. Potential side effects from steroid administration may include transient flushing, restlessness and elevation of blood sugar. You should follow up with your referring physician's office in 10 to 14 days, unless instructed otherwise, accompanied with your questionnaire and a copy of your fluoroscopic image for evaluation.



FACET JOINT INJECTION

Overview

Facet joints are small paired joints throughout the spine that provide you with stability and flexibility.

Painful facet joints develop as a result of arthritis, trauma or continual stress.

The primary goal of facet joint injections (FJI) is to provide pain relief by reducing inflammation. Secondarily, facet joint injections may help verify or refute potential source of pain.

Pain caused by cervical facet joints may be felt in the neck, shoulders, shoulder blades, upper arm(s) and head. Lumbar facet joints may cause pain in the lower back, buttocks, hips and legs. Thoracic facet joint pain may be noticed in the upper back and chest.

Procedure

After an initial consultation with Dr. Chang and your questions answered satisfactory, you will be escorted to a procedure suite and positioned on the fluoroscopic table. You can either remain awake during the procedure or intravenous sedation may be administered to lessen anxiety. The target site is cleansed with antiseptic solution and sterilely draped. The skin over the injection site is numbed with a local anesthetic. A thin needle is then inserted into the facet joint(s) under X-ray guidance. Once needle placement is confirmed with contrast medium, (figure 3), a local anesthetic (bupivicaine) and/or steroid (triamcinolone) is then deposited. The whole process takes approximately twenty to thirty minutes.

Post Procedure

Most patients are able to leave the clinic upon completion of the procedure. A pain questionnaire may need to be filled out over the next several hours to document treatment response. If your pain goes away after the injection, it can be inferred that the targeted facet joint(s) is your pain generator. Although facet injections may provide long lasting relief, many do not. If relief lasts longer than several months, injections may certainly be repeated. However, if dramatic but brief relief is obtained, more diagnostic injections such as Medial Branch Blocks may be more appropriate. Potential side effects from steroid administration may include transient flushing, restlessness and elevation of blood sugar. You should follow up with your referring physician's office in ten to fourteen days, unless instructed otherwise, accompanied with your questionnaire for evaluation.



MEDIAL BRANCH BLOCK

Overview

Medial branch nerves are small nerve branches that communicate pain caused by the facet joints, (see FACET JOINT INJECTION). Each facet joint is innervated by two medial branch nerves.

These procedures are primarily diagnostic and are performed when the facet joints are considered potential sources of your neck and back pain.

By anesthetizing these medial branch nerves, this will temporarily block the transmission of pain signals to and from the joint(s). If dramatic reduction of pain is derived (greater than 80%), you will likely to benefit from radiofrequency neurotomy.

Procedure

After an initial consultation with Dr. Chang and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned on the fluoroscopic table. You can either remain awake during the procedure or intravenous sedation may be administered to lessen anxiety. The target site is cleansed with antiseptic solution and sterilely draped. The skin over the injection site is numbed with a local anesthetic. A thin needle is then inserted onto the targeted medial branch nerves that are located along bony grooves near the base of the transverse processes within under X-ray guidance. Once needle placement is confirmed with contrast medium, a local anesthetic (bupivicaine) is then deposited. The whole process takes approximately twenty to thirty minutes.

If dramatic reduction of pain is noticed and lasting the appropriate duration of the injected local anesthetic, than you will be considered an ideal candidate to undergo Facet Neurotomy in hopes of long lasting relief.



FACET RHIZOTOMY/RADIOFREQUENCY NEUROTOMY

Overview

Once you have been diagnosed with facet pain syndrome and have failed to respond to conservative treatments, this procedure may provide you with long term relief.

Radiofrequency neurotomy interrupts the pain signal delivered by the medial branch nerves to the facet joint(s) thus alleviates facet mediated pain. (Please see Facet Joint Injection and Medial Branch Block)

Although the goal of facet rhizotomy is pain relief, no guarantee can be given in regards to the quality of improvement nor the duration of relief. Furthermore, if your pain in the neck or back stems from any other structures in addition to the facet joint(s), such as your disc(s), your may only derive partial reduction in pain or none at all.

Procedure

After a consultation with Dr. Chang and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned prone on the fluoroscopic table. You can either remain awake during the procedure or intravenous sedation may be administered to lessen anxiety. The target site is cleansed with antiseptic solution and sterilely draped. The skin over the injection site is numbed with a local anesthetic. A thin probe is then inserted onto the medial branch nerves under X-ray guidance. Probe placement is confirmed with electrical impulses and you will be asked if any pain or tingling sensation is noticed in your arm or leg. Once probe placement is deemed satisfactory, a controlled heat lesion will occur to sever the medial branch nerves and denervate the facet joint(s) of interest. Each nerve is subjected to three or four discrete lesions at 85 degrees Celsius for 90 seconds each. The whole process takes approximately forty-five minutes to one hour.

Post Procedure

Most patients are able to leave the clinic upon completion of the procedure. Avoid strenuous activities over the next 24 to 48 hours. Application of ice and oral intake of analgesics usually will alleviate soreness over the injection site although flair-ups are possible. Even though the facet joint(s) are denervated upon completion of the procedure, you may experience soreness over the next two to three weeks secondary to tissue irritation caused by the heat lesions. Potential side effects from steroid administration may include transient flushing, restlessness and elevation of blood sugar. You should follow up with your referring physician's office in three to four weeks and report overall treatment response.



SACROILIAC JOINT INJECTION

Overview

Sacroiliac joint injections are performed for diagnostic and therapeutic intentions for lower back pain associated with sacroiliac (SI) joint dysfunction.

The sacroiliac joint is located between the sacrum (bottom of the spine) and the pelvis (hip).

Sacroiliac joint pain maybe difficult to diagnosis due to lack of accurate imaging study, physical examination, as well as similarity to pain caused by disc herniation and lumbar spinal nerve compression.

The sacroiliac joint is the cause of your low back pain if dramatic reduction of pain is derived after deposition of local anesthetic into the joint itself.

Procedure

After an initial consultation with Dr. Chang and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned prone on the fluoroscopic table. You can either remain awake during the procedure or intravenous sedation may be administered to lessen anxiety. The target site is cleansed with antiseptic solution and sterilely draped. The skin over the injection site is numbed with a local anesthetic. A thin needle is then inserted into the sacroiliac joint under X-ray guidance. Once needle placement is confirmed with contrast medium, (figure 4), combination of a long-lasting steroid (triamcinolone) and a local anesthetic (bupivicaine) are deposited. The whole process takes approximately twenty to thirty minutes.

Post Procedure

Most patients are able to leave the clinic upon completion of the procedure. Be aware of potential numbness and weakness of your leg(s) and avoid strenuous activities over the next 24 to 48 hours. Application of ice and oral intake of mild analgesics usually will alleviate potential soreness over the injection site although flair-ups are possible. Potential side effects from steroid administration may include transient flushing, restlessness and elevation of blood sugar. You should follow up with your referring physician's office in 10 to 14 days, unless instructed otherwise, and report overall treatment response. There are no consensus in the medical community regarding the frequency of sacroiliac joint injections, the most prudent recommendation suggests evaluation of each and every injection prior to further treatments are planned.



DISCOGRAM

Overview

A discogram is a diagnostic injection performed to evaluate the integrity of your disc(s) and determine if the disc(s) is the source of your pain.

Each disc is composed of two parts:

1) A tough outer portion called annulus fibrosus composed of collagen fibers, and

2) A inner core called nucleus pulpous composed of mucoprotein gel

A disc may become painful secondary to degeneration, annular tear or herniation.

Discogram is performed when your disc(s) is considered a primary suspect of your pain generator. Although numerous imaging studies such as CT and MRI may reveal structural abnormalities of discs, not all abnormal discs are painful, and not all painful discs are abnormal. Therefore, it is near impossible to diagnose discogenic pain based solely on imaging studies or physical examinations.

Asides from confirming whether a disc is painful or not, discograms are also frequently performed to evaluate the structural integrity of the discs above and below a proposed fusion segment prior to surgical intervention.

Procedure

After an initial consultation with Dr. Chang and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned prone on the fluoroscopic table. You can either remain awake during the needle insertion portion of the procedure or intravenous sedation may be administered to lessen anxiety. The target sites are cleansed with antiseptic solution and sterilely draped. Intravenous antibiotics will be given to lessen the chance of disc space infection which is a rare but feared complication. The skin over the injection sites are numbed with local anesthetics. A thin needle is then inserted into the nucleus of each targeted disc under X-ray guidance. Once needle placement is confirmed, (figure 5), you will need to be fully alert and oriented before initiation of the pressurization sequence. Each disc is then individually pressurized with a mixture of contrast medium and antibiotics through a pressure manometer syringe that will document the generated pressure in pounds per square inch.

Due to the subjective nature of discogram, you have to pay close attention to what you are feeling.
Dr. Chang needs to know whether any discs upon pressurization causes you:

1) Concordant (similar) or Discordant (dissimilar) Pain
2) Mild, moderate or severe pain intensity (per pain scale)
3) Presence or absence of radicular pain in the extremities
4) Pressure sensation only
5) Nothing

After each disc is pressurized and documented, intravenous narcotics may be given to lessen any discomfort caused by the procedure. The whole process takes approximately sixty minutes.

Post Procedure

Most patients are able to leave the clinic upon completion of the procedure. Avoid strenuous activities over the next 24 to 48 hours. Application of ice and oral intake of analgesics usually will alleviate soreness over the injection site although flair-ups are possible. You will be given a set of fluoroscopic images along with a discogram work sheet to be brought back to your referring physician's office for evaluation.