Our Services
We specialize in the interventional pain management. Depending on the patient's particular condition, treatment plans also encompass support, counseling and coping strategies for well-rounded pain suppression.
Strategies can include:
 
 

 

 

 

© 2001 Advanced Pain Management Center, P.C.

 

 

 

Last updated on 4/2004

 

 

Vertebroplasty

Introduction

Vertebroplasty ( V-plasty) is a minimally invasive procedure done primarily to releive pain caused by compression fracture of the spinal vertebrae (spinal bone). A compression fracture occurs when pressure on the bone making up the spine causes it to break. During the V-plasty a physician injects bone cement into the affected vertebra which stabilizes the bone and relieve pain. The procedure is most effective for fractures that are less than six month old. If you have a medical condition that prevents you from lying on your stomach for one to two hours , if you have a bleeding disorder or can not be taken off blood thinners you may not be good candidate for V-plasty

How is it done?

Prior to having V-plasty, it’s necessary to have an X-Ray of the spine as well as MRI or bone scan. These tests help to identify which vertebrae are fractured and how recently the fracture occurred. Your health care provider will examine you and evaluate your test results.
The procedure is done in X-Ray room. It will require mild to moderate IV sedation and therefore you will need to have an IV line. You will be asked to lie on the your stomach on the X-Ray table. The skin over the affected vertebrae will be cleaned and sterile towels placed around the area. The skin and the bone will be numbed with local anesthetic. Then specially designed needle is inserted into bone utilizing the X-Ray camera. When the needle is in correct position, bone cement is injected into the vertebrae. The X-Ray camera allows your physician to observe the cement as it’s injected. It’s usually necessary to insert two needles into the vertebrae to complete the procedure.

1. Vertebral Compression Fracture, causing pain and spinal deformity. 2. A biopsy needle is guided into the fractured vertebra through a small incision in the skin.

Inset: magnified view of the interior of the osteoporotic vertebra with the needle in place.
3. Acrylic bone cement is shown flowing into the vertebra, filling the spaces within the bone.

Inset: Magnified view of the interior of the vertebra with the cement filling in the spaces.		 4. Restored vertebra with hardened cement, stabilizing the vertebral structure and relieving pain.

Inset: Magnified view of the interior of the restored vertebra.

 

What is the recovery like?

Once the procedure is over, you will be taken to a room where you will be asked to lie flat on your back for approximately 1-2 hours. This gives the bone cement the chance to harden . After resting for several hours you may be discharged home. Occasionally there is a need to stay in the hospital overnight and you should be prepared for it.
You can remove the bandages covering the injection sites on your back in 48 hours following V-plasty. Remember to return to normal activities gradually. You also have to maintain contact with your primary doctor for treatment of the cause of the fracture since V-plasty treats only the fracture but not the underlying disease.

Follow the discharge instructions and call APMC (503)295-0730 if you have any questions.

Benefit Vs Risks

More than 80% of people experience significant pain relief following this procedure. However, there are some risks you should be aware of. The primary risk is that bone cement may leak from the vertebrae into surrounding tissues and blood vessels. If cement leaks toward the spinal cord or nerve roots the resultant pressure on this structures may cause pain and weakness. This is rare. If bone cement enters blood vessels surrounding the vertebrae it could travel to the lung, causing vessel blockage that may result in chest pain and breathing difficulties. This is also rare. If you have osteoporosis (soft bones) you may be at increased risk for rib fracture from lying on your stomach during the procedure. Occasionally the treated bone can refracture and you may require another treatment.

Other risks include but are not limited to:
Infection,
Bleeding,
Further fracture of the vertebrae from needle placement.

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IntraDiscal ElectroTermal Therapy

Introduction

IntraDiscal electroThermal therapy using IntraDiscal catheter is a fairly recent addition to the treatments for patients with painful degenerative disc disease. FDA has cleared the device. This technology provides a treatment in a minimally invasive manner. The IntraDiscal catheter delivers thermal energy directly to the disc via a resistive heating coil. It is designed for creating temperature-controlled coagulation and for shrinking collagenous tissue. This in turn is expected to promote collagen shrinkage relieving pressure of a disrupted disc, to enhance structural integrity of the disc and reduce disc volume, to cauterize neural receptors responsible for pain inside the disc.

How is it done?

The procedure is performed in X-Ray suite. Intravenous sedation is available for the procedure and is recommended. A nurse who also monitors your vital signs does this. The level of sedation is titrated to your comfort but an attempt is made to avoid very heavy sedation since feedback from you is important for a safety of a procedure. Firstly, sterile conditions are achieved and then local anesthetic is used to numb your skin and deeper tissues. Secondly, introducer needle is placed into the painful disc and then IntraDiscal catheter is advanced through it under the X-Ray guidance. Once an appropriate catheter position is confirmed the generator delivering the thermal energy is activated. The temperature is increased gradually and it is expected to reproduce your usual symptoms, however you have to report any new pain and /or pain in the legs right away. The therapy level can be adjusted to accommodate for any severe or unusual discomfort. According to current recommendations, the ideal temperature to be reached is 80 to 90 degrees C for 4-6 min.

1. X-Ray showing the needle advancing into the disc. 2. X-Ray imaging shows the SpineCATH positioned and heating the intervertebral disc.

What is the recovery like?

Most patients will experience an increase in their typical pain (back, back and leg) after procedure. It usually subsides over the first 1-14 days. The improvement in your symptoms may or may not be fast. If only one disc was treated you should expect to feel the results within 4-12 weeks. Two disc treatments can take longer, 6-20 weeks. The pain medication may be prescribed to you to help with postoperative discomfort. You will be given written guidelines for activity restrictions following the procedure. It will include wearing a lumbar corset within first 6 weeks while collagen restructuring takes place. It is very important to actually wear it and this can not be overemphasized. Between 8-12 weeks, depending on your comfort level, you should start physical therapy program. Gradual increase in exercise regimen is important and is designed to assure your back stabilization. It will continue at a minimum of 6 month.

Benefit Vs Risks

Efficacy of this procedure is still being evaluated but according to published reports and interpersonal physician’s communications approximately 70% of the patients are satisfied with their outcome at 6-month follow-up. Majority of those patients report an improvement in general overall activity levels. About 30% of the patients feel the same or worse than before undergoing the procedure. In general IDET is a safe, minimally invasive therapy providing the physician with a definitive approach to addressing pain from the painful disc. However, you have to be aware of the potential risks of this procedure so you can make an informed decision. As discussed above temporary worsening of pain can occur and can sometimes last for longer then usual 2 weeks. Infection of the disc is a significant complication though very rare. You will be given intravenous and IntraDiscal antibiotics to prevent it. But any intense unusual pain in the back, fever and /or chills should be reported immediately. Other potential but rare complications include infection and /or bleeding in the spinal space sometimes even requiring surgery, trauma of the nerve roots exiting spinal cord. The alternative to this procedure is surgery, usually discectomy and /or fusion. Whether you are a good candidate for this should be discussed with your surgeon.

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Epidural Steroid Injection

Introduction

Epidural space is wrapped around the spinal fluid sack and spinal nerves like an empty donut ring. If spinal nerves are swelled and/or pinched by the inflammation, herniated disc or narrowing of the spinal canal you can experience pain. Steroids, a type of anti-inflammatory medication injected into the epidural space may decrease swelling so the nerve is no longer irritated or pinched and your pain may improve.

How is it done?

To perform the injection, you will be positioned on your stomach. The skin overlying the procedure site will be numbed with injection of local anesthetic and then special needle will be inserted under the X-Ray guidance into your epidural space. You may feel a strong sensation of pressure or cramping in your back, legs or buttocks. The injected fluid putting extra pressure on the swollen nerves causes this.

What is the recovery like?

Steroids can take days to weeks to decrease the swelling and inflammation and the results may not be apparent right away. You will be scheduled for total of three injections 2-3 weeks apart. By the time your third injection is done you should know whether this treatment is going to give you enough of the long-term benefit or other options for your treatment need to be considered.

Benefit Vs Risks

There are certain side effects and /or complications you need to be aware of:

  1. The injected area may be sore or bruised for several days. It’s usually well resolved
  2. You may have a minor muscle spasm in the area of injection. This is usually controlled well with application of the icepack or Tylenol
  3. You may have increase in symptoms for several days until steroids begin to work
  4. Rarely, “spinal headache” may occur. It usually results from inadvertent puncture of the sleeve holding the spinal fluid in place. This may cause severe headache for several days, blurred vision and/or ringing in the ears. These symptoms will usually go away in 3-7 days. Treatment may range from bed rest, plenty of beverages containing caffeine, Tylenol etc. to specialized procedures that are usually very effective.
  5. You may have temporary increase in your blood sugar and/or labile blood pressure if you are suffering from diabetes or prone to hypertension. This is due to the side effects of steroids and usually requires an adjustment of your medications for several days.
  6. There is very small risk of infection or bleeding into the epidural space.
    Those may be serious complications requiring emergency surgery. Fortunately its exceedingly rare occurrence.
    However, it’s very important that you inform APMC staff if you are taking any blood thinning medications including aspirin like drugs. Those would need to be discontinued several days prior to the procedure.

What to do after epidural steroid injection?

  1. Continue your medication. Do not stop or decrease the dose until you are instructed to do so by your doctor.
  2. Continue all exercises prescribed by physical therapy. You can exert yourself to tolerance. This activity is very important for the recovery of function.
  3. You may return to work the next day. However, on the day of the procedure do not drive and do not walk outside unless you are accompanied by an adult friend or family member.
  4. Follow the discharge instructions and call APMC (503) 295-0730 if you have any questions.

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Nucleoplasty ( Percutaneous Disc Decompression)

Introduction

By definition, percutaneous disc decompression is a minimally invasive surgery designed to relieve pressure of a small-herniated disc on surrounding spinal structures. It does not require a surgical incision but rather is performed through a needle. This is a well-established procedure and has been performed for the past 20 years. Over the years, different techniques have been used to remove the pressure exerted by small disc herniations including chemical, mechanical and laser decompression.
Most recently, this procedure was performed utilizing mechanical or thermal removal of the disc material. Mechanical removal of the disc is accomplished with Dekompressor - specially designed percutaneous discectomy probe with threads. Thermal procedure (Coblation Nucleoplasty) utilizes so-called Coblation technology. During Coblation Nucleoplasty radiofrequency energy is applied to the nucleus of the disc causing low-heat, molecular dissociation and vaporization of the part of nuclear tissue. This, in turn is expected to reduce disc herniation. It’s not really clear at this time whether one procedure has an advantage over the other. However, with the use of Dekompressor the removed disc material can actually be visualized.

How is it done?

The procedure is performed in X-Ray suite. Intravenous sedation is available for the procedure and is recommended. A nurse who also monitors your vital signs does this. The level of sedation is titrated to your comfort but an attempt is made to avoid very heavy sedation since feedback from you is important for a safety of a procedure.
Firstly, sterile conditions are achieved and then local anesthetic is used to numb your skin and deeper tissues.
Secondly, introducer needle is placed into the herniated disc and then special probe is advanced through the needle under the X-Ray guidance. Further technique depends on the actual procedure being performed. With the use of Dekompressor once an appropriate probe position is confirmed the device is turned on and turning threads of the Dekompressor mechanically remove the disc tissue. In case of Coblation Nucleoplasty the generator delivering the radiofrequency energy is activated. The Coblation effect is achieved at temperatures of approximately 40-70 degrees C . The wand is used to create several channels within the nucleus and then removed. The therapy usually takes 10-20 minutes.

What is the recovery like?

Most patients tolerate this procedure fairly well . However, you may experience an increase in your typical pain (back, back and leg) after procedure. It usually subsides over the first 1-14 days. The improvement in your symptoms may or may not be fast. If only one disc was treated you should expect to feel the results within 1-2 weeks. Two disc treatments can take longer, 2-4 weeks. The pain medication may be prescribed to you to help with postoperative discomfort.

At this time there are no special guidelines for activity restrictions following this procedure. Rather, activities need to be structured to tolerance with gradual return to baseline level of function over 1-4 weeks. It’s recommended to stay of work 2-3 days for those with desk-like job. Patients who are expected to return to heavy physical exertion environment may need to be off work longer, up to 1-2 weeks. Between 2-4 weeks, depending on your comfort level, you may start physical therapy program.

Benefit Vs Risks

Efficacy of this procedure is still being evaluated but according to published reports and interpersonal physician’s communications approximately 70% of the patients are satisfied with their outcome at 6-month follow-up. Majority of those patients’ report an improvement in general overall activity levels: sitting, standing, walking etc.
In general Percutaneous Disc Decompression is a safe, minimally invasive therapy providing the physician with a definitive approach to addressing pain from the small herniated disc. However, you have to be aware of the potential risks of this procedure so you can make an informed decision.

As discussed above temporary worsening of pain can occur and can sometimes last for longer then usual 2 weeks. Infection of the disc is a significant complication though very rare. You will be given intravenous and intradiscal antibiotics to prevent it. But any intense unusual pain in the back, fever and /or chills should be reported immediately. Other potential but rare complications include infection and /or bleeding in the spinal space sometimes even requiring surgery, trauma of the nerve roots exiting spinal cord.
The alternative to this procedure is surgery, usually discectomy. Whether you are a good candidate for this should be discussed with our surgeon.herniation. It’s not really clear at this time whether one procedure has an advantage over the other. However, with the use of Dekompressor the removed disc material can actually be visualized.

Medial Branch Blocks and Radiofrequency Denervation

Introduction

You and your doctor have decided that it is appropriate for you to have diagnostic medial branch (facet joint nerve) blocks. The purpose of this procedure is to find out if the facet joints in your neck or back are responsible for your pain. If the blocks reveal this to be the case, you may consider medial branch denervation, or "permanent" nerve block. Below we will explain the goals of this therapy as well as the procedures. Please feel free to ask your doctor and nurses for more detailed information or explanation.

Therapeutic rationale:

Throughout the entire spine there are joints called facet joints. These joints are located in pairs along the posterior (back) of the spinal column but are not very close to the actual spinal cord. These joints are small and somewhat fragile and are prone to injury in certain types of traumatic, inflammatory or degenerative conditions. They also have a nerve supply that is capable of referring pain to the central neck, low back and buttocks. Unfortunately the joints cannot be repaired or replaced. However, the nerve supply to the joint can be affected. That is what these procedures do. In some cases spinal fusion surgery is an option. The denervation process has the potential advantage of avoiding or delaying surgery.

Diagnostic medial branch (facet nerve) blocks: In both the cervical (neck) and the lumbar (low back) regions the nerve that blocked with local anesthetic (numbing medication). This procedure allows you and your doctor to assess the role that these joints play in your pain problem. If your pain is made significantly better for a temporary period after the diagnostic block that may mean that the joint is responsible for your pain. If this is the case, the block will be repeated on one other occasion to verify the effect.

Sometimes you may experience long lasting pain relief after these injections. During the procedure you will be placed on the examination table in the procedure suite. The doctor will use fluoroscopy (x-ray) to locate the appropriate place for the block. A local anesthetic will be used to numb your skin. After that a sterile needle will be placed under x-ray guidance into the vicinity of the medial branch nerve. When positioning of the needle is acceptable, a small amount of local anesthetic will be injected.

You may experience some discomfort during the procedure but your doctor will be as gentle as possible. Remember that you are in charge and may request a pause if you feel that it is necessary. Typically, you will receive minimal sedation during this part of the procedure. This is important because the sedation medications will interfere with the interpretation of the results of the procedure. You will be under the care of your doctor performing the procedure and a pain management nurse will closely monitor you during the procedure. If your pain is no affected by the diagnostic block, it may be that the facet joint is not responsible for your pain. In this case, you and your doctor will need to find a different plan to treat your pain.

Radiofrequency denervation of the facet joint:

If you have had a series of diagnostic blocks and pain continues to be a problem, you and your doctor may elect to try a long-term solution. The nerve to the facet joints can be destroyed by the use of a special technique called radiofrequency denervation. In this technique, a special needle is placed under x-ray guidance. When the needle is in the correct position, it is attached to the radiofrequency generator. The generator gives your doctor the ability to verify the position of the needles in relationship to the nerves in the area. When your doctor is sure the location is appropriate and safe, the radiofrequency generator will be used to heat the tissue at the end of the needle. This will destroy the nerve that supplies the facet joint.
If necessary, this procedure will be repeated at several levels as determined by the results of your diagnostic blocks. Since the procedure is more uncomfortable than the diagnostic blocks and since the important decision have been made by this time, you will have sedation and pain relieving medication administered intravenously during the denervation. The sedation may be administered by the nurse under the direct supervision of the doctor.

Goals of facet denervation:

This procedure is not designed to eliminate all of your pain. Unfortunately, that result is not usually a realistic expectation. However, it may substantially reduce the pain that you experience directly due to your facet joints. This will allow you to perform physical therapy that you were previously unable to do. This post-procedural physical therapy is very important to your recovery and is generally different that physical therapy that you have done previously.

Common questions and concerns

My pain relief was only temporary after the diagnostic block. Is that a failure?
No. The diagnostic blocks may or may not produce long-lasting pain relief. It is generally difficult to predict. They are mostly designed to find out if temporary reduction of nerve function results in temporary relief of pain. If blocks are effective for some time but pain persists, it may be appropriate to try a denervation procedure.

Isn't it bad to destroy nerve? Don't I need them?
Generally speaking, yes. In this case, however, there is not a great risk with the destructive procedure. This is a minor nerve that only serves the joint and a small muscle that may also be responsible for your pain. Unless an entire series of these nerves are damaged you won't notice the loss. Often, injury to a large nerve or one that supplies the skin results in increased pain. This is not generally the case after these procedures because of the way in which the radiofrequency lesion is generated.

Will the nerve grow back?
Yes, in 3-12 months the nerve will generally grow back. Since the radiofrequency lesion does not physically disrupt the nerve like a scalpel would, the regenerating nerve will not create a neuroma (another painful condition). When the nerve grows back, some of the discomfort may return but not necessarily.

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Diagnostic Provocative Discography

Introduction

The intervertebral disc is a frequent cause of persistent back pain. Pain may be generated by the irritation of neural structures adjacent to the disc or by a stimulation of the nerve endings in the disc itself. Diagnostic imaging studies such as x-ray, CT san or MRI are helpful if structural damage to the disc is large enough to cause disc herniaton. However, it is often difficult to see small tears in the disc and then diagnostic provactive discography can be very helpful.

This procedure is done by precision injection of contrast dye into the disc nucleus. As a result, nerve endings in the disc are stimulated. The stimulus applied with discography has two components - a chemical stimulus resulting from contact between the contrast dye and sensitized tissues, and a mechanical stimulus resulting from fluid distension. The physician performing discography expects to reproduce your clinical symptoms thereby confirming the disc as a source of pain.

What's next?

The identification of particular intervertebral discs as a source of pain leads to several therapeutic options. Minimally invasive intradiscal electrothermotherapy is available for treatment of lumbar disc pain. This procedure is relatively new but has already gained wide acceptance in the medical community and shows good promise. Discectomy and spinal fusion are surgical procedures and can be viewed as other options for treating a painful disc. Your neurological or orthopedic surgeon should determine whether you are a candidate for surgery.

How is it done?

Discography is performed with x-ray guidance in a fluoroscopy suite. Intravenous sedation is available for the procedure. A nurse, who also monitors your vital signs, does this. However, an attempt is made at keeping the sedation minimal because feedback from you is important to the outcome of this procedure. The procedure is done under sterile conditions; local anesthetic is used to numb the skin. Under x-ray guidance a needle is placed into the disc. Several discs usually need to be injected for a study to be complete and meaningful.
Once the needles are in place, the contrast solution is injected. You may or may not have discomfort during this injection. It is very important to communicate any pain or discomfort to your doctor. It is also very important to distinguish between the pain that you usually experience and pain related to the procedure. Since the diagnostic value of this procedure is based to a significant degree on provoking your pain, discomfort during the procedure is to be expected. However, it is very appropriate to request a pause during the procedure if the discomfort is unbearable

Is this procedure dangerous?

Most patients tolerate this procedure fairly well . However, you may experience an increase in your typical pain (back, back and leg) after procedure. It usually subsides over the first 1-14 days. The improvement in your symptoms may or may not be fast. If only one disc was treated you should expect to feel the results within 1-2 weeks. Two disc treatments can take longer, 2-4 weeks. The pain medication may be prescribed to you to help with postoperative discomfort.

At this time there are no special guidelines for activity restrictions following this procedure. Rather, activities need to be structured to tolerance with gradual return to baseline level of function over 1-4 weeks. It’s recommended to stay of work 2-3 days for those with desk-like job. Patients who are expected to return to heavy physical exertion environment may need to be off work longer, up to 1-2 weeks. Between 2-4 weeks, depending on your comfort level, you may start physical therapy program.

Discography is not considered to be a dangerous procedure. However, there are certain risks associated with it. The most significant complication is infection of the disc. The rate of infection is 0-1.3% per disc according to data available. Recent publications of experience of three centers performing large volume discography procedures showed a 0% rate of infection. You will be given both intravenous and intradiscal antibiotics as prophylaxis against infection. Nevertheless, if you experience intense, unusual back pain, fever and/or chills after the procedure, you should let us know immediately.

Other complications include increased pain after the procedure, infection of the epidural space, which may require surgery, trauma of nerve roots exiting the spinal cord, or pneumothorax (punctured lung). These complications are rare, however, you should be aware of the risk so you can ask appropriate questions and make an informed decision before consenting to the procedure.
Please ask your provider for additional explanation if you have any questions.

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Myofascial release and manual therapy / therapeutic massage

Introduction

Your provider has referred you for manual therapy and/or myofascial release. These bodywork techniques can release painful muscle tension, improve circulation, increase joint flexibility, and reduce mental and physical fatigue. But the question most people want answered before their first appointment is "What will it actually be like?"

The techniques used during your appointment may include stroking, deep kneading, surface friction, light tapping and joint movement. Specialized techniques are utilized to relieve painful trigger points, relax contracted fascia (the muscles' protective coverings), realign and heal injured tissue, aid lymph drainage, or restore natural balance and flow of energy throughout the body.

Your therapist has completed many hours of education, which included a variety of bodywork techniques, extensive anatomy and physiology, and knowledge of when manual therapy or myofascial release is and is not appropriate. Feel free to ask your therapist about their unique combination of specialized training and education.

What is the first appointment like?

Your therapist will begin by asking you general health questions since there are some conditions for which this therapy is not appropriate. Depending you the primary technique your therapist uses, you may or may not be asked to undress. Your therapist will give you privacy to undress and you are normally covered except for the area being worked on.
You will lie on a padded table designed for stability and comfort. Your therapist may offer cushions or an adjustable face rest for support. The room will be warm and quiet, often with soft music playing. For many techniques your therapist will use a lubricant, such as light oil or lotion, which is good for your skin and absorbs well. For some kinds of bodywork, no oil is used.
A session usually begins with relatively gentle pressure to calm your nervous system and begin releasing superficial tension. Gradually your therapist works more deeply to address specific areas.

What should I do during my therapy session?

Make yourself comfortable. If your therapist wants you to adjust your position you will be informed. Otherwise change your position anytime to make yourself more comfortable. Many people just close their eyes and relax completely during a session; others prefer to talk. Do not hesitate to ask questions at any time. The desire to sigh or take a deep breath is a sign that you are relaxing.

How will this therapy feel?

Manual therapy or myofascial release on healthy tissue feels good. The normal response is to slow down, breathe deeply and relax.
The saying "not pain, no gain" is not true for this type of therapy. The most effective and deepest therapy works with the body's natural responses, not against them. Working in the area of an injury or chronic pain may at first cause some discomfort, which usually lessens in the first few minutes. Your therapist knows ways to minimize pain, and will work carefully within what feels right to you. Always tell your therapist if you feel any discomfort.

What should I expect afterwards?

Manual therapy and myofascial release can profoundly affect all your body's systems. Give yourself a moment to reorient before slowly getting up. After a session most people feel very relaxed. Many experience freedom from aches and pains. After an initial period of feeling slowed down, some people often experience an increase in energy that can last for several days. Sometimes you may not feel dramatic results right away. Watch for changes over the course of your prescribed therapeutic treatment.

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