Conservative Treatments

STOSSA's Conservative Approach:

Please select from the the list of links below to learn more about each.

Body Braces	Medications
Physical Therapy	Injections
Electro Stimulation	Psychology

Body Braces

Anterior Cervical Orthosis (ACO)
These can be either soft or rigid. Soft collars are often used for minor cervical injury and can provide a great deal of comfort after a "whiplash" injury. Rigid collars are commonly used as a postoperative treatment to assist in neck immobilization. They can also be used to temporarily treat instability of the cervical spine.

Thoracolumbosacral Orthosis (TLSO)
This is usually a rigid brace and comes in various styles. It is designed to immobilize the upper and lower back. It is commonly used in thoracic or lumbar spinal fractures, and also during postoperative periods.

Lumbosacral Orthosis, Lumbar Corset, Back Brace (LSO)
Lumbar corsets can be rigid or soft. They provide support for the lumbar spine, help reduce the load on back muscles, and are helpful during episodes of acute and chronic low back pain. They are also used for support after spine surgery such as discectomy, and fusion surgeries. Patients should avoid becoming dependent on the lumbar corsets. If they are used for prolonged periods (weeks and months), the back muscles may begin to weaken and cause a patient to be more prone to reinjury.

Back and Neck Braces

Introduction
If you are diagnosed with a spinal disorder, deformity, or potential problem that can by helped through the use of external structural support, your physician may recommend the use of a back or neck brace. Braces offer a safe, non-invasive way to prevent future problems or to help you heal from a current condition.
The use of braces is widely accepted. They are effective tools in the treatment of spine disorders. In fact, more than 99% of orthopedic physicians advocate using them.
Braces are really nothing new. They have actually been around for centuries. Lumbosacral corsets (for the lower back) were used as far back as 2000 B.C.! Bandage and splint braces were used in 500 A.D. in an effort to correct scoliosis (a spine with a sideways curve). Recently, braces have become a popular way to actually help prevent primary and secondary lower back pain from ever occurring.

There are more than 30 types of back supports available for spine disorders. This website will discuss several common types and why they are used.

This website will cover:
Neck Braces, Trochanteric Belts, Sacroiliac and Lumbosacral Belts, Corsets, Rigid Braces, Hyperextension Braces, Molded Jackets, Lifting Belts, Clinical Uses, Goals of Spinal Bracing, Possible Drawbacks

Neck Braces

Neck braces are used to provide stability of the cervical spine after neck surgery, a trauma to the neck, or as an alternative to surgery. They are probably the type of spinal brace you most commonly see people wearing. There are several types available, including:

Soft Collar - This flexible brace is placed around the neck. It is typically used after a more rigid collar has been worn for the major healing. It is used as a transition to wearing no collar.

Philadelphia Collar - This is a more rigid/stiff collar that has a front and back piece that attaches with Velcro on the sides. It is usually worn 24 hours a day until your physician instructs you to remove it. This collar is used for conditions such as: a relatively stable cervical (upper spine) fracture, cervical fusion surgery, or a cervical strain. Another similar type is the Miami cervical brace.

Sterno-Occipital Mandibular Immobilization Device (SOMI) - A SOMI is a brace that holds your neck in a straight line that matches up with your spine. It offers rigid support to a damaged neck and prevents the head from moving around. With this brace, you are unable to bend or twist your neck. The restriction of motion helps the muscles and bones to heal from injury or surgery.

If you look at what the name means, you will better understand what a SOMI does: "sterno" means your upper and middle chest, "occipital" is the base of your skull, "mandibular" refers to your jaw and chin, and "immobilization" describes the support and movement restriction the brace offers. The SOMI is worn on the parts of the body for which it is named. First, there is a chin piece that the lower jaw rests on. Second, the chin piece connects by straps to a headband that is worn across the forehead. Third, the chin piece connects to a chest piece by a front metal extension. Finally, the chest piece then rests on the upper and middle chest - sort of like a vest. This connects to the occipital piece, which supports the base of the head.

This brace is obviously a bit more complicated and cumbersome than some of the others, but it provides excellent support for an injured neck.

Halo - The main purpose of the halo is to immobilize the head and neck. This is the most rigid of the cervical braces. It is only used after complex cervical spine surgery or if there is an unstable cervical fracture. The halo looks a lot like the word sounds. It has a titanium ring (halo) that goes around your head, secured to the skull by four metal pins. The ring then attaches by four bars to a vest that is worn on the chest. The vest offers the weight to hold the ring and neck steadily in place. The Halo is worn 24 hours a day until the spine injury heals.

Trochanteric Belts
The trochanteric belt is usually prescribed for sacroiliac joint pain or pelvic fractures. The belt fits around the pelvis, between the trochanter (a bony portion below the neck of your thigh bone) and the iliac (pelvis) ridges/crests. It is about five to eight centimeters wide and it buckles in front, just like a regular belt.

Sacroiliac and Lumbosacral Belts
The lumbosacral belt helps to stabilize the lower back. These belts are usually made of heavy cotton reinforced by lightweight stays. The pressure can be adjusted through laces on the side or back of the belt. These belts range in widths between 10 to 15 centimeters, and 20 to 30 centimeters. The sacroiliac belt is used to prevent motion by putting a compressive force on the joints between the hipbone and sacrum (base of the spine).

Corsets
Corsets provide rigidity and support for the back. Corsets can vary in length. A shorter or longer corset will be prescribed, depending upon your condition. A short corset is typically used for low back pain, while a longer one is used for problems in the mid to lower thoracic spine. When people think of corsets, they usually conjure up images of women from earlier centuries who used them to make their waists look smaller. Today, in the treatment of back problems, corsets refer to a type of back brace that extends over the buttocks and is often held up by shoulder straps. Like the corsets of old, these lace up from the back, side, or front. There are metal stays that provide the appropriate rigidity and support for the back.

Rigid Braces
These braces are typically prescribed for low back pain and instability. If greater rigidity is needed to support the spine than can be found in standard back supports, rigid frame spinal bracing is often prescribed. These are stiff braces. They usually consist of rear uprights that contour to the lumbar (lower) spine and pelvis, along with thoracic bands. There are also fabric straps on the braces that provide pressure in the front. Common types of rigid models are:
Williams Brace - This type of brace has no vertical uprights in the middle so that flexion/bending is allowed.
Chair-back Brace - This type immobilizes the lumbar spine in the neutral position. The chair-back is designed to reduce sideways and revolving movement of the lower spine.
Raney Flexion Jacket - This type reduces lumbar lordosis by holding the patient in a neutral tilt.

Hyperextension Braces
This brace is designed to prevent excessive bending, and it is often prescribed to treat frontal compression fractures that have occurred around the junction of the thoracic and lumbar spine. The brace can also be used for post surgery healing from a spinal fusion. These braces offer support that allows anterior (front) pressure unloading of the thoracic vertebrae by restricting flexion (bending) of the thoracic and lumbar spine. Hyperextension braces have a front rectangular metal frame that puts pressure over the upper sternum and the pubis/pubic bone. This encourages spinal extension. There is opposing pressure applied over the T-10 level (the tenth vertebra in your thoracic spine). The braces offer what is called "three-point stabilization" to the spine through a front abdominal pad, a chest pad, and a rear pad at the level of the fracture. By applying pressure in three-points - sternal, pubis and rear Lumbosacral - the spine is extended/stretched. The sternum is the narrow, flat bone in the front middle of thorax. The thorax is the portion of body between the base of the neck and the lower diaphragm. The most common types of Hyperextension Braces are Knight Taylor and Jewett.

Molded Jackets
These jackets are designed to distribute pressure widely over a large area. By immobilizing the patient from the neck to the hips, pressure is distributed evenly, taking excess pressure off overloaded or unstable areas. These jackets were originally made of plaster of Paris, but now are typically made out of molded plastic.

Lifting Belts
These belts are designed to reduce low back strain and muscle fatigue that can occur when you are lifting heavy objects. The belt circles around the waist, covering the lumbar region of the spine, and closes in front. These belts are usually made of cloth or canvas and do not have stays. Some models also have lordosis pads.

Clinical Uses
The braces/supports are most frequently used to treat: low back pain, trauma, infections, muscular weakness, neck conditions, and osteoporosis. Braces, belts, and jackets are designed to immobilize and support the spine when there is a condition that needs to be treated. Depending on the model that is used, they can put the spine in a: neutral, upright, hyper-extended, flexed, or lateral-flexed position.

Goals of Spinal Bracing
Spinal bracing is used for a variety of reasons such as to: control pain, lessen the chance of further injury, allow healing to take place, compensate for muscle weakness, or prevent or correct a deformity. More specifically, lumbar corsets and braces compress the abdomen, which increases the intra-abdominal pressure. This act allows pressure on the vertebral column to unload, providing some relief. There are other reasons bracing is used. One is the theory that they insulate the skin, producing increased warmth that decreases the sensation of pain - much like a heating pad. Another reason is that the increase in abdominal pressure produces hydraulic support for the back. Finally, certain types of movement may cause stress to the pain generators in the back. The decrease in range of movement by using bracing may relieve this type of pain.

Possible Drawbacks
Though the effects of bracing are primarily positive, they can lead to a loss of muscle function, due to inactivity. Bracing can sometimes lead to psychological addiction, so that even when the patient is healed and ready to be taken off the back brace, he or she feels dependent upon it for physical support.

Medications

MEDICATIONS
Medications may be prescribed for pain, inflammation and muscular discomfort related to neck or back problems. The following information is general by design and is for educational purposes only. It is important to be evaluated and diagnosed by a health care provider before starting or stopping any medications.

The following medications are used in the treatment of spine:
ANTI-DEPRESSANTS
MUSCLE RELAXANTS
NARCOTIC PAIN MEDICATIONS
NEUROPATHIC MEDICATIONS
NON-NARCOTIC PAIN MEDICATIONS
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
STEROIDS

MEDICATION REFILL POLICY
The STOSSA is available to refill prescription medications Monday through Thursday 8:00am-3:00pm, and Friday 8:00am -12:00 noon.
The STOSSA recommends that patients use one pharmacy for their medications and refills. Using one pharmacy allows the pharmacist to cross reference medications and to warn of any possible drug interactions.

Please allow 24 hours for all medication refills. We prefer that patients call their pharmacy for refills.

No medications will be refilled over the weekend or after hours.

STEROIDS
Corticosteroids are potent anti-inflammatory agents which affect many organ systems. By reducing inflammation, pain is often reduced. Corticosteroids may be used to treat the following conditions: arthritis, bursitis, ankylosing spondylitis, acute tenosynovitis, systemic lupus erythematosis, asthma, allergic reactions, ulcerative colitis, and exacerbations of multiple sclerosis. Although there are many benefits to steroid use, steroids are also associated with decreased bone healing, decreased efficiency of the immune system, osteoporosis, and avascular necrosis of the hip. Steroids may be taken orally (by mouth), intramuscularly (by injection), or by injection into specific areas of the spine.

Examples include:

TRADE NAME	GENERIC NAME
Cortef Decadron Deltasone Medrol	Hydrocortisone Dexamethasone Prednisone Methylprednisolo

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
Like steroids, NSAIDs are medications that are designed to reduce inflammation. Arthritic conditions and related disorders cause the production and release of prostaglandins from cell membrane constituents. Prostaglandins cause edema, cellular exudation, and pain. NSAIDs exert their effects primarily through inhibition of prostaglandin synthesis. NSAIDs inhibit cyclooxygenase (COX), the enzyme responsible for the conversion of arachadonic acid into prostaglandins. There are at least two forms of this enzyme. The COX-1 isoenzyme produces those prostaglandins that protect the stomach lining. COX-2 produces the prostaglandins that mediate an inflammatory response. Non selective NSAIDs, such as, ibuprofen and Naproxen, inhibit the activity of both COX-1 and COX-2 so they treat pain and inflammation but may damage the stomach lining. Newer NSAIDS, that are COX-2 selective (Bextra, Celebrex, and Vioxx), have been shown to be gentler on the stomach and less likely to cause stomach or duodenal ulcers.

Examples include:

TRADE NAME	GENERIC NAME
Advil Anaprox Ansaid Arthrotec Bayer Cataflam Celebrex Clinoril Daypro Dolobid Ecotrin Feldene Indocin Lodine Mobic Motrin Naprosyn Naprelan Nuprin Oruvail Relafen Voltaren-XR	Ibuprofen Naproxensodium Flurbiprofen Dicolfenac/misoprostol Aspirin ASA Diclofenac Celecoxib Sulindac Oxaprozin Diflunisal Ecotrin ASA Piroxicam Indomethacin Etodolac Meloxicam Ibuprofen Naproxen Naproxen Ibuprofen Ketoprofen Nabumetone Diclofenac sodium

ANTI-DEPRESSANTS
Anti-depressant medications may be used in addition to pain medications for those patients with chronic pain. It is common for patients with chronic pain to need an antidepressant medication to help them sleep, cope with mood swings, and manage their pain more effectively. Patients should be monitored closely on these medications.

Examples include:

TRADE NAME	GENERIC NAME
Celexa Effexor Elavil Lexapro Paxil Prozac Remeron Wellbutrin Zoloft	Citalopram XR Venlafaxine Amitriptyline Escitalopram Paroxetine Fluoxetine Mirtazapine Bupropion Sertraline

MUSCLE RELAXANTS
Muscle relaxants are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions. These medications are not intended for long term use. Muscle relaxers can be sedating and, as with all sedatives, driving and alcohol intake should be restricted.

Examples include:

TRADE NAME	GENERIC NAME
Dantrium Flexeril Lioresal Norflex Parafon Robaxin Skelaxin Soma Valium Zanaflex	Dantrolene Cyclobenezaprine Baclofen Orphenadrine Forte Chlorozoxazone Methocarbamol Metaxalone Carisoprodol Diazepam Tizanidinee

NEUROPATHIC MEDS
Neuropathic medications treat neuralgia (nerve pain). A nerve that is compressed, pinched, or damaged may cause a "misfire", or short circuit, of the nerve signal. The brain interprets the short circuit as sharp, stabbing, shooting, burning, or stinging pain. In the absence of structural damage, these medications can help with regulate neurotransmission. These medications are also used to treat seizure disorders, diabetic peripheral neuropathy, and nerve pain caused by shingles. They may also be very sedating. When taking these medications, do not take any anti-anxiety medication (Valium, Xanax, Ativan, Klonopin, etc.).

Examples include:

TRADE NAME	GENERIC NAME
Neurontin lyrica Topamax Zonegran	Gabapentin Pregabalin Topiramate Zonisamide

NARCOTIC PAIN MEDICATIONS
Analgesics or pain medications are designed to block pain. Narcotic pain medications are necessary for those patients suffering from severe pain. Narcotics are highly addictive and have significant side effects. These medications should be taken cautiously. We recommend that you do not drive while taking these medications. The STOSSA does not prescribe long term pain medications. Patients who require long term narcotic use will be referred to a pain management physician.

Examples include:

TRADE NAME	GENERIC NAME
Darvocet N-100 Duragesic patch * Lortab / MS Contin * Norco Oxycontin * Percocet * Talwin NX Vicodin	Propoxephene/acetaminophen Fentanyl Hydrocodone/acetaminophen Morphine sulfate Hydrocodone/acetaminophen oxycodone Oxycodone/acetaminophen Pentazocine/naloxone Hydrocodone/acetaminophen

* Requires hand-written prescription monthly and may not be called into the pharmacy

NON-NARCOTIC PAIN MEDICATIONS
Non-narcotic pain medications are also analgesics. They are designed to block the pain signal relayed to the brain via the nervous system. Tylenol (generic name - acetaminophen) is the most well-known non-narcotic, over-the-counter medication. Be sure to follow the instructions on the bottle for dosing this medication which may be harmful to the liver if overdosed. An adult should not consume more than 3000 mg. of Tylenol (acetaminophen) in a 24 hour period which is equivalent to 6-8 extra strength Tylenol.

Examples include:

TRADE NAME	GENERIC NAME
Esgic Fioricet Fiorinol Norgesic Tylenol Ultram Ultracet	Acetaminophen/butalbitol/caffeine Acetaminophen/butalbitol/caffeine ASA/butalbitol/caffeine Orphenedrine/ASA/caffeine Acetaminophen Tramadol Tramadol/ Acetaminophen

DISCLAIMER
spinetex.com does not provide medical advice. Information on this site is general in nature and is provided for informational purposes only. The information is NOT medical advice and no physician/patient relationship is created by virtue of the information provided on centerforspinecare.com. The content is, in no way, intended to substitute for consulting a medical professional. While reasonable attempts are made to ascertain the accuracy of this general information, no representation or warranty is made by STOSSA as to the accuracy of the information. We do not assume liability for any of the content of the material presented on the website. The decision to rely on information found on the website or a linked website is solely at your own risk. STOSSA does not and cannot provide specific medical advice through this website or by e-mail in response to any inquiry that you may make. If you have a specific medical problem or specific medical inquiry, it is important that you contact your personal physician and seek professional medical advice which is focused on your individual situation. Never disregard medical advice as a result of something which you may have read on the centerforspinecare.com website. Centerforspinecare.com accepts no liability for injury or damage resulting from your decision to use any product, information or instruction found on the website or on sites linked to the website. STOSSA welcomes an opportunity to provide you with medical services, and if you wish to make an appointment, please contact our office in person or by telephone at 210-561-7234.

Physical Therapy

Physical Therapy Modalities

For more information, visit orthopedic manual physical therapy.com Hot packs, cold packs, ultrasound, iontophoresis, electrical stimulation, TENS (Transcutaneous Electrical Nerve Stimulation), NMES (Neuromuscular Electrical Stimulation), IF (Interferential Current).

Traction

Traction is performed for temporary relief of neck or back pain. Small amounts of weight are placed to create distraction forces in order to relieve pain and spasm.

Myofascial Release

This involves hands-on techniques that are somewhat similar to deep tissue massage. It is sometimes uncomfortable but is often helpful in reducing spasm in hard-to-stretch areas.

Postural education

One of the keys to preventing reinjury to the spine is education. Posture is a very important factor in avoiding a relapse of a spinal injury. During initial phases of physical therapy visits, patients receive instructions on proper posture.

Body Mechanics

This is another vital part of spine education. The average person does a great deal of bending, lifting, and possibly twisting on any given day. These movements are commonly associated with the onset of back pain or sciatic symptoms. Therapists give instruction on proper ways to perform these activities, and also point out movements that should be avoided at all times. It is important to continue to follow proper body mechanics after the injury and throughout the rest of your life.

Stretching and Stabilization

There are a number of exercises for the spine. Most of them require no special equipment, and can be performed on the floor either with the therapist or at home. They include stretching and stabilization exercises, which produce low amounts of stress and strain at the point of injury, yet help greatly with proper alignment and stabilization of the spine.

Resistance Training

Once a patient is showing improvement of pain and adequate efficiency of the basic stretches and stabilization exercises, it is time to move on the more intense muscle building routines. These include use of weight machines specifically designed to focus on the back, abdominal, and oblique muscles. During this phase, it is extremely important that a patient uses the proper technique with the machines in order to avoid making the injury worse.

Work Hardening

This is a work specific type of therapy that is usually implemented after the initial phase of physical therapy is completed. These programs are designed to simulate normal occupational activities in a controlled environment, under the supervision of a therapist.

Sports Preparation

Patients that have been active in sports prior to an injury can get help returning to their respective sport with a careful and sport specific training program after their initial spine problem has been addressed. This will help patients return to the previous level of activity, and decreases the likelihood of reinjury due to a particular sport (Golf, basketball, softball, football, etc.).

Aquatic Therapy

In some patients, land based physical therapy may make symptoms worse. These patients can often benefit from aquatic physical therapy, which reduces the mechanical stress effects of gravity. Aquatic therapy also helps with cardiac conditioning; cardiac workload increases by approximately 3 times once someone is submerged in water up to his or her neck. This is due to an increase in efficiency of blood return to the heart. Aquatic therapy allows you to get the same cardiac benefit as doing approximately one third of the exercise. This however does not translate to improved fat burning.

Electrical Stimulation as a Pain Management Treatment

Electrical Stimulation - Pain Management Treatments

Neurostimulation is indicated as an aid for management of chronic, intractable pain of the neck, back, and limbs. Neurostimulation delivers precisely controlled, mild electrical impulses to the spinal cord or to a peripheral nerve. Neurostimulation is a proven effective alternative to repeated back surgery, medication, or other therapies. Neurostimulation uses a small system that is surgically placed under the skin to send mild electrical impulses to the spinal cord or to a peripheral nerve. The electrical impulses are delivered through a lead that is also surgically placed. These electrical impulses block the pain signal from reaching the brain. Because neurostimulation works in the area where pain signals travel, electrical impulses can be directed to cover specific sites where you are feeling pain. Neurostimulation can give effective pain relief and decrease the need for pain medications. In addition, this therapy is non-destructive. Typically, patients who have success with neurostimulation experience a 50% greater reduction in their pain and improved ability to go about daily activities.

Injections as Pain Management Treatments

Epidural Injections

The epidural space is within the spinal canal and surrounds the spinal cord. Steroid injections into this space can help to decrease inflammation of nerves and other soft tissues in the problematic area. These injections are usually given in a set of three for a cumulative effect. They are used for problems such as: Herniated discs, Sciatica, Radiculopathy, Narrowing of the Spinal Canal (Spinal Stenosis), and occasionally for Discogenic Low Back Pain. They can be given in the neck (cervical spine), upper back (thoracic spine), lower back (lumbar spine), and from the level of the tailbone (caudal approach).

Facet Injections

Facet joints are the joints in the posterior portion of the spine. There is one set of two facet joints between each vertebra in the spine. These joints can commonly be affected by arthritis and can cause back pain. Injections of local anesthetic and steroid can be used to relieve this pain.

Selective Nerve Root Blocks/Transforaminal Epidural Injection

Nerve root blocks use medications such as local anesthetics or steroids to disable a specific nerve root that is causing pain. Nerve root injury can often be localized by electrodiagnostic testing, and can be caused by herniated discs, stenosis, facet cysts, whiplash, or hyperextension injuries.

Sympathetic Blocks

These blocks are used to disrupt an abnormal pain cycle that can be caused by an overactive sympathetic nervous system. This condition is commonly referred to as complex regional pain syndrome (CRPS). It is also known as reflex sympathetic dystrophy (RSD), causalgia, shoulder hand syndrome, or sympathetic pain syndrome.

Intrathecal Pain Pump (Morphine Pump)

Intrathecal drug delivery systems are indicated for chronic intractable pain, cancer pain, and for chronic spasticity. Intrathecal drug delivery has been shown to increase pain relief and comfort for people with severe pain. It may also cause fewer side effects than oral medications. These benefits may help people with chronic pain improve their quality of life and participate more fully in daily activities. Delivery makes the difference with intrathecal drug delivery. This therapy uses a small pump that is surgically placed under the skin of the abdomen to deliver medication directly in to the intrathecal space (the area surrounding the spinal cord). The medication is delivered through a small, soft tube called a catheter that is also surgically placed. The spinal cord is like a highway for pain signals on their way to the brain, where your body experiences the feeling of pain. Because the drug is delivered directly to where pain signals travel, intrathecal drug delivery offers significant pain control, with a small fraction of the dose that would be required with pills. This helps minimize side effects. Clinical studies show that of people who did not experience enough pain relief with high doses of oral medication, most achieved significant pain control with intrathecal drug delivery and were able to improve their activities of daily living.

Spinal Injections

Introduction

In many cases of chronic back pain spinal injections may be used both to find out what is causing your pain and to treat your pain. Doctors refer to these two separate uses of spinal injections as diagnostic and therapeutic. If an injection provides pain relief in the area that is injected, it is likely that this particular area is the source of the problem. Injections are also therapeutic in that they can provide temporary relief from pain.

Learn about spinal injections including
what medications are injected
what types of injections are used
why you might choose to have an injection
why you might choose not to have an injection

Medications

With most spinal injections, a local anesthetic (numbing medication) called lidocaine (also known as Xylocaine) is injected into a specific area of the spine. Lidocaine is a fast-acting drug, but the effects wear off within about two hours. That is why lidocaine is used more often as a diagnostic tool rather than a long-lasting pain reliever. Bupivacaine (also known as Marcaine) is another type of anesthetic that can be used. It is slower to take effect, but it lasts longer, giving the patient more relief from pain. Cortisone is a strong anti-inflammatory steroid medication. It is commonly injected along with a local anesthetic in order to reduce inflammation in the affected areas. Cortisone is long lasting and can be slow-releasing in order to give the best possible benefits of pain relief. Cortisone may not begin working for several days following the injection, but the effects can last for months. Sometimes a narcotic medication such as morphine or fentanyl is mixed with cortisone and the anesthetic to get increased pain relief.

Injections

Epidural Steroid Injection (ESI)
Facet Joint Injections
Hardware Injections
SI Joint Injections
Differential Lower Extremity Injections
Epidural Steroid Injection (ESI)

An ESI is a common type of injection that is given to provide relief from certain types of low back and neck pain. The "epidural space" is the space between the covering of the spinal cord (dura mater) and the inside of the bony spinal canal. It runs the entire length of your spine. When injected into this area the medication moves freely up and down the spine to coat the nerve roots and the outside lining of the facet joints near the area of injection. For example, if the injection is given in the lumbar spine, the medication will usually affect the entire lower portion of the spine. Find out more about preparation before the procedure.

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

There are three different ways to perform an epidural injection:

caudal block
translumbar
transforaminal
Caudal Block

Caudal Block

A caudal block is placed through the sacral gap (a space below the lumbar spine near the sacrum). The injection is placed into the epidural space. This type of block usually affects the spinal nerves at the end of the spinal canal near the sacrum. This collection of nerves is called the cauda equina. One of the benefits of this type of injection is less chance of puncturing the dura.

Translumbar

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

Transforaminal

The transforaminal approach is a very selective injection around a specific nerve root. The foraminae are small openings between your vertebrae through which the nerve roots exit the spinal canal and enter the body. By injecting medication around a specific nerve root, the doctor can determine if this nerve root is causing the problem. This type of epidural injection is used most often for diagnostic purposes, and it is commonly used in the neck.
Reasons why you may want to have an ESI.

Reasons why you may NOT want to have an ESI.

Facet Joint Injections

Facet joint injections are used to localize and treat low back pain caused by problems of the facet joints. These joints are located on each side of the vertebrae. They join the vertebrae together and allow the spine to move with flexibility. The facet joint injections form a pain block that allows the doctor to confirm that a facet joint is causing the pain. The medication used also decreases inflammation that occurs in the joint from arthritis and joint degeneration.
It is important to make sure that the injection goes directly into the facet joint. Fluoroscopy can be used to confirm that the needle is in the right position before any medication is injected. A fluoroscope uses X-rays to show a TV image. You doctor can watch on the screen as the needle is placed into the joint and magnify the image to increase accuracy.

There are two types of facet joint injections.

Interarticular are injected directly into the joint to block the pain and reduce inflammation.

Nerve blocks help determine whether the joint is indeed a source of pain by blocking the small nerves that connect with the joint.

Specific Indications

A facet joint injection is perhaps the best way to diagnose facet joint syndrome. Joints that look abnormal on an X-ray may in fact be painless, while joints that look fine may actually be a source of pain. This is a rather simple procedure with little risk.

Hardware Injections

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

Specific Indications

These injections are used to determine whether a specific piece of hardware is causing the pain and needs to be removed surgically.

SI Joint Injections

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

Specific Indications

SI joint injections can be used both to treat pain and to determine the source of the pain. This injection usually requires the use of fluoroscopic guidance or a CT scan in order to make sure the needle is placed correctly in the joint.

Differential Lower Extremity Injections

Various types of injections into certain areas of the lower extremities can help your doctor decide where the pain is starting. Pain that comes from problems with the back and the spinal nerves can mimic many other conditions. Sometimes it is impossible to tell if the pain you are experiencing is due to a back condition or a problem in your hip, knee, or foot. To help determine whether a joint of your lower limb is causing you pain, your doctor may suggest injecting medication, such as lidocaine, into the joint to numb the area. Once the medication is injected, if the pain goes away immediately, that joint is more likely to be the source of the pain than your back. Your doctor can then focus on finding the problem in the joint.

General Contraindication

When certain medical conditions are present, doctors may determine it is unsafe to perform a spinal injection. Your doctor will discuss any concerns with you before making a final decision.

Bleeding Tendencies

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

Infections

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

Unstable Medical Conditions

Injections are usually an elective procedure offered to patients without life-threatening conditions. A medically unstable patient should have his or her medical condition treated before any elective injections are given.

General Precautions

Consider these basic warnings before choosing to have a spinal injection.
If you are chronically taking a platelet-inhibiting drug, such as aspirin or NSAIDs (non-steroidal anti-inflammatory drugs), you have an increased risk of bleeding and might not be a candidate for a spinal injection.

If you are hypersensitive or have certain allergies to medications, you may have a negative reaction to the drugs used in the injection. Make sure to give your provider a list of your allergies.
If you have an accompanying medical illness, you should discuss the risks of spinal injections with your physician. For instance, patients with diabetes mellitus might experience an increase in blood sugar after an injection with cortisone. Patients with congestive heart failure, renal failure, hypertension, or a significant cardiac disease may have problems due to the effects of fluid retention several days after an injection.

Psychology

Pain Management Treatments: Psychology

PAIN CONTRIBUTORS:

Depression

Depression is a common finding in chronic back pain sufferers. There is some question as to which comes first, the back pain or the depression. Either way, the depression should be considered and treated in order to have the best possible results from all other treatments.

Stress

Stress related to work or other aspects of life will commonly exacerbate back and neck pain. It is important to identify these stressors, and deal with them in a way that does not adversely affect the pain.

Fear and Anxiety

Fear and Anxiety is often generated when a source of pain has been present past a normal period of recovery. Questions begin to develop regarding the cause of pain. Do I have cancer? Am I going to be paralyzed? Fear and anxiety that begins to develop can make the pain seem greater than it is.

Disrupted Sleep Cycle

Disrupted Sleep Cycle due to pain can cause agitation, fatigue, malaise, mood swings, and irritability. These can all cause the pain to intensify. Reestablishing proper sleep cycle is one of the first steps in treating chronic pain.

TREATMENTS:

Relaxation

Relaxation techniques are used to remind a patient to relax mentally and physically in order to decrease discomfort in an affected area of the spine. Mental and physical stress may sometimes contribute to neck or back pain and discomfort.

Distraction

Distraction techniques are used to distract your mind away from the pain. These will sometimes include hobbies, which force the brain to focus on something other than the pain.

Pacing

Pacing is very important in the recovery process. It is used to help control the amount of work a patient performs in a given amount of time, to avoid re-injury or fatigue that can cause rebound pain.

Biofeedback

Biofeedback is a treatment, which uses electrodes to monitor muscular activity in the affected area of the spine, and displays it on a computer screen. This enables the patient to visualize the relaxation of muscles. This often times helps in decreasing the amount of "stress" that can settle in the back.

Body Braces

Medications

Physical Therapy

Injections

Electro Stimulation

Psychology