Concord Orthopaedics, P.A.

Transcription

1 Cncrd Orthpaedics, P.A. PART IV: HOW IS THE INJECTION DONE? Why Inject? An injectin is intended t: T decrease pain T imprve functin T eliminate r reduce the need fr pain medicatin T diagnse Sme believe respnse t a guided and specific spinal injectin can be diagnstic f a specific spine prblem. It is nt at all clear that is true. Sme experts believe specific injectin can differentiate between disc pain, facet pain, sacr-iliac pain, etc. I am nt sure I agree. I am nt even cnvinced that specific injectin can differentiate between pain f spinal rigin and pain f peripheral rigin, i.e. neck vs. shulder r back vs. hip r knee. With that said, it is my impressin that there is mre diagnstic value in spinal injectin when trying t differentiate between spine and peripheral pain than there is when trying t differentiate between pain f different spine structures. What part(s) f the spine d we inject? The spine is a cmplicated structure. It must serve a dual rle f supprting ur bdy while allwing it t mve. Therefre, it needs t be strng, yet flexible. It must als prtect ur spinal crd. T accmplish this, it is cmpsed f a tube within a tube. The inner tube is a sac, called the dura, which is filled with spinal fluid. In the upper part f the spine, the sac als cntains the spinal crd. In the lumbar spine, in adults, the sac cntains spinal nerves but nt the spinal crd. In this arrangement, the uter, structural, bney tube serves t prtect the spinal crd and spinal nerves. The uter tube is cmpsed f a stack f bnes called vertebrae. The vertebrae are cnnected in the frnt by intervertebral discs and in the back by a pair f facet jints. The vertebrae vary in size and shape depending n their lcatin. The spine is divided int the cervical spine (neck) with 7 vertebrae, the thracic spine (chest) with 12 vertebrae which attach t ribs, the lumbar spine (lw back) with 5 vertebrae, the sacrum with 5 vertebrae which cnnects t the pelvis thrugh the sacr-iliac jint, and the cccyx, r tail bne, with 5 vertebrae. Vertebrae are lettered by the type f vertebrae and numbered frm tp t bttm based again n tp. Fr example, the 5 th thracic vertebrae frm the tp is referred t as T-5.

2 The intervertebral discs are cables which hld the bnes tgether. The uter prtin is referred t as the annulus, which functins t hld the bnes tgether, and the inner prtin, which is referred t as the nucleus, serves t dampen shck t the spine. Discs are numbered based n the tw vertebrae they cnnect. Fr example, the disc which cnnects C5 t C6 is called the C5-6 disc. Discs are injured when the uter annulus is trn. This is referred t as an annular tear. Mst ften, such injuries are painless. When enugh tears accumulate in an area, this causes the disc t bulge. Again, this is mst ften painless. If enugh tears ccur t allw the nucleus t migrate twards the Page 2 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

3 utside f the annulus, this is called a prtrusin r herniatin. If the disc leaks ttally ut f the cnfines f the annulus, this is called an extrusin. Interestingly, mst prtrusins and extrusins are als painless. Why these prblems becme painful in sme individuals remains a mystery. When disc degeneratin ccurs, it becmes less effective at its twin tasks f hlding vertebrae tgether and absrbing shck. When this happens, lad is transferred t the vertebrae, supprting ligaments, and facet jints. In respnse, they thicken. As they thicken, they have the capacity t narrw the spinal canal prducing stensis. If this happens in the middle f the spine, this is referred t as central stensis. If this happens n the side, it is referred t as lateral stensis. Again, stensis is usually painless. Again, why stensis becmes painful in sme peple is a mystery. The prgressin f degeneratin is referred t as the degenerative cascade. Where the spine cnnects t the pelvis is referred t as the sacr-iliac jint. The sacrum is a part f the lwer spine. This prtin f the spine is a slid bne with n discs r facet jints. Each f these structures, disc, facet, spinal nerve, and sacriliac jint can becme injured and inflamed. When injury des nt respnd t rutine treatment, these structures can be injected with crticsterids. Page 3 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

4 Hw d we inject? Any jint in the bdy can be treated with crtisne injectin. Mst injectins are dne blindly. This means the physician identifies the spt t be injected by visual inspectin and by feel. Fr mst injectins, this is accurate. Fr the spine and the hip, thugh, that is nt true. All spinal injectins are typically dne under flurscpy r x-ray guidance. This is mre t prmte accuracy than t prmte safety, as mst spinal injectins can be dne safely, thugh nt accurately, withut x-ray. Because f the need t use x-ray guidance, the prcedure must be dne in a facility that is x-ray cmpatible. In ur facility, it is dne in an perating rm. Please nte: the prcedure is a crtisne injectin. It is nt an peratin! Preparing fr the injectin. Attend yur cnsultatin Have any pain medicatin issues reslved with yur referring prvider Ntify me if yu are n bld thinners (Plavix r Cumadin). These must be discntinued several days befre the prcedure. They can be resumed immediately after the prcedure. This is a clean prcedure. Therefre, patients with artificial jints, artificial heart valves, r ther heart valve issues d nt need t take prphylactic antibitics. Ntify me if yu are allergic t latex, band-aids, betadine, lidcaine, crtisne, r x-ray dyes. Ntify me if yu are an insulin dependent diabetic D nt plan any physical activity which invlves frceful bending r twisting r heavy lifting fr 3-4 days after the prcedure. If yu need a nte fr reduced activity frm wrk during this perid f time nly, I can prvide this. Make sure yu have a ride if needed. Of nte, we d allw sme peple t drive themselves hme after the injectin. This must be apprved in advance. Yu cannt drive yurself if yu live mre than 25 miles away r have taken a sedative. If yu are very nervus abut the prcedure, make arrangements in advance with me t receive an ral sedative. We d nt prvide intravenus sedatin (cnscius r uncnscius). Ntify us if yu are r may be pregnant. Ntify us if yu have a histry f passing ut with expsure t needles r ther medical prcedures. Ntify us if yu have an acute infectin f any type. The day f the prcedure Eat as yu nrmally wuld Take yur medicatins as yu nrmally wuld (except fr Cumadin and Plavix) Arrive at the time yu were ntified by the OSC staff. Please nte, this time is 30 minutes befre the injectin is planned t begin. Page 4 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

5 Wear lse fitting clthing. The prcedure The nurse will bring yu back t the pre-perative rm. I will meet with yu and g ver any changes since ur meeting r since ur last injectin. Yu will walk int the prcedural rm. Yu will lie n yur belly n the prcedural table. We psitin pillws under yur waist, chest, and lwer legs t rund yur back and keep yu cmfrtable. If yu are nt, we will d what we can g make yu cmfrtable. An x-ray machine will be placed ver yu. It is small enugh that many peple d nt ntice it. There is a viewing screen. Yu are welcme t watch if yu wish. I will begin by cleaning yur skin with betadine r ther antiseptic if yu are allergic t betadine I will then numb yur skin and muscles with lidcaine. Yu will feel this part. We will then put a needle in place. At this pint, yu shuld nly feel pressure. If any part f the prcedure is uncmfrtable after yur skin has been numbed, please let me knw! We will take steps t make yu mre cmfrtable. Fr facet, cccyx, and sacr-iliac injectins, the needle is placed directly in the jint as depicted in the diagrams belw. Mst peple d feel sme pain when the needle enters the jint. Often, if the jint is the cause f yur pain (pain generatr), yu will feel a reprductin f yur pain. This is nrmal. Fr epidural injectins, the needle is placed in the epidural space which is the space between the bne and the dural sac as utlined in the diagram belw. Translaminar and Transframinal Epidural injectin Page 5 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

6 Caudal Epidural Injectin Lumbar Facet Injectin Sacriliac Jint Injectin The spinal canal can be entered thrugh the midline (trans-laminar epidural), n the side where the nerve exits (transframinal) r at the bttm f the sacrum (caudal). Mst ften, we use the trans-laminar apprach. In certain circumstances, we will use the ther appraches. Each apprach has its unique prs and cns, and I will discuss that with yu befrehand. All lumbar and thracic injectins are dne frm the level belw the prblem with a few exceptins. All cervical injectins are dne at C7-T1. The epidural space at this level is large and cnsistent frm patient t patient. As ne mves up the neck, the space shrinks r Page 6 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

7 becmes nn-existent, and it is nt safe t g higher. I d nt d trans-framinal injectins abve the lumbar spine as I d nt believe ptential benefits utweigh the risks. Depending n ther factrs, such as severe stensis r pst-perative changes, I may need t mdify the apprach. I will discuss any such changes thrughly with yu in advance. Once the needle is in place, I will cnfirm accuracy by injecting sme x-ray cntrast r dye. In ding this, we wish t make sure f the fllwing: the needle is in the jint fr facet, cccygeal, r SI injectins the needle in the epidural space fr epidural injectin. We want t make sure that the needle is nt in a vein. There are many epidural veins, and it is cmmn t hit ne r be in ne. Hitting ne is nt the prblem. The nly prblem with injecting in a vein is that the medicine will travel systemically, nt t the area we wish t address. The needle is nt in the dural sac/spinal fluid. This is referred t as a spinal. This apprach is used fr myelgrams, spinal anesthesia, and diagnstic spinal taps. It is nt clear if injectin f crtisne int the spinal fluid (intrathecal space) is therapeutically helpful, therefre, we need t be aware f such psitining. A ptential cmplicatin is a spinal headache (see belw). If the needle is nt in prper psitin, I will adjust its psitin until I am satisfied it is in place. Once the needle psitin is satisfactry, I will inject the medicine. Typically, the injectate is a mixture f lidcaine and dep-medrl. At times, I will use ther agents. In cervical epidurals, the tw agents are nt mixed, and are injected separately. Please nte, yu will prbably feel smething when we inject. Usually, the sensatin is a pressure sensatin. In cervical injectins, yu may feel a wave f clness r warmth ver yur chest r back. Smetimes, yu will feel pain. Usually this is a reprductin f yur typical pain, althugh it may be different. The severity f the pain is directly related t the rate f increase in pressure caused by placing fluid in the tight epidural space. It can be cntrlled by the rate f injectin. We encurage yu t tell us if yu are uncmfrtable s I can make adjustments in the rate at which I inject. Immediately after the prcedure Yu will be taken t the pst-perative area. While there, yu will be mnitred t be sure yur vital signs are stable and that yu have nt develped a spinal, epidural, r peripheral nerve blck. This wuld mean yu wuld be experiencing numbness and/r weakness belw the site f injectin. These are nt cmplicatins. In fact, this effect is intended when epidurals are used fr anesthesia. It is ur bservatin that rughly 1 in 200 patients will develp this. The effect will wear ff usually in 1 t 4 hurs. We will have yu stay until we feel yu can ambulate safely. Yu will be given an instructin sheet with the fllwing: What t d and what nt t d What prblems may arise, and what t if they arise. Page 7 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

8 Where t call if prblems arise. Yur next appintment with me r yur referring prvider What t Expect after the Prcedure What is nrmal Mst peple d nt feel better immediately. 20% feel better immediately, 20% feel wrse fr a few days. 60% will feel better after a few days r a few weeks. It is unusual t have a lng term imprvement with the first injectin. Mst peple require 2 t 3 injectins t get the peak effect. It is nt unusual t see n respnse t the first injectin, yet still d well with the series. If the first injectin des nt help, d nt despair. We strngly encurage yu t d the secnd. If yu ntice n respnse t bth f the first 2 injectins, yur likelihd f success diminishes substantially. Sme still d well. With that in mind, if yu get n relief frm the first tw injectins, I leave it up t yu if yu wish t prceed. A lw grade temperature within 24 hurs after the prcedure. Bruising r swelling r lcal discmfrt at the injectin site A slight elevatin in bld pressure fr a few days A persistent ht flash in pst-menpausal wmen lasting several days What is nt nrmal An increase in pain fr mre than 7 days after the prcedure. A severe increase in pain immediately after the prcedure An increased temperature mre than 24 hurs after Any change in sensatin, strength, r bwel r bladder functin A severe frntal headache beginning within 24 hurs f the prcedure An increase in bld sugar in diabetics ver 300 mg/dl. If this happens, please cntact the dctr wh manages yur diabetes. There is n need t call fr any f the nrmal events. Fr the nt nrmal events please cntact us immediately. Fr any issues nt related t the injectin, please cntact yur referring dctr. Activities after the Prcedure Crtisne can mask yur pain sensitivity fr a few days after the prcedure, s it is imprtant t limit yur activities fr 3-4 days. Yu can: Drive Walk Ride bike ver even terrain D stretching exercises Yu shuldn t: D any activities which invlve any frceful bending r twisting such as raking, shveling, vacuuming, glf, etc. Avid heavy lifting. Avid any activities which adversely affected yu pain befre the injectin Avid trying any new, physically strenuus activities After 4 days, yu can challenge yurself. If yu have questins abut yur activity, please ask. Plan n staying n yur pre-prcedural pain medicatins fr at least 7 days pstprcedure. Page 8 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

9 Risks Cmmn, self limited Increased pain fr a few days Lcalized bleeding Lcalized swelling Lw grade temperature Reactins t crtisne: anxiety, increased appetite, swelling in ankles Uncmmn Severe headache (spinal headache). This usually abates after 2-3 days and is treated with bed rest and fluids. If it persists, it respnds 95% f the time t an epidural bld patch. This invlves intrducing cc (3 tsp) f yur bld int the epidural space. Severe pain lasting mre than a few days. It is my experience this usually abates within a week, but may require ral crticsterids. Nerve injury. This usually results frm using the transframinal epidural apprach in patients with severe stensis, lateral disc herniatin at the level injected, r previus surgery at the level injected. The pain is typically within the distributin f the nerve injured, and usually abates within a few weeks. This is avided by nt injecting in the areas described. Vas-vagal reactin (faint). This is self limited and easily treated Numbness r weakness. This is typically due t nerve r epidural blck and abates within a few hurs. Rarely may it last a few days. We have nt seen this effect last mre than a few days. Rare Infectin. As f the writing f this mngram, we have had ne infectin in ver 20,000 injectins. This infectin respnded t antibitics. Paralysis: we have nt seen this happen, nr have I heard f it happening in an in-ut epidural. There are reprts f paralysis ccurring frm in-dwelling epidural catheters which becme infected, r frm cervical epidurals where the needle is placed in a stentic area where there is effectively n epidural space. The prblem is avided by nt placing the needle is such areas. Strke. This cmplicatin has been reprted with the use f particulate sterids in trans-framinal cervical epidurals when the needle has entered the vertebral artery. It is because f this risk that I d nt use this apprach t cervical epidurals Persistent pain Outcmes Unfrtunately, the literature n bth lng and shrt term utcmes with spinal injectin is sparse and cntradictry. Mst f the literature fcuses n the treatment f herniated lumbar discs. There is virtually n data n utcmes fr cervical r thracic injectin, r fr stensis in any part f the spine. There is als n useful data n utcmes fr cccygeal r sacriliac injectin. There is evidence t suggest that facet injectin is nly useful as a prgnstic indicatr fr medial-branch radi-frequency ablatin. With that said, it is generally felt that 60% f patients with spine pain assciated with limb pain will d well with epidural injectin fr a perid f time and can avid surgery. It is cmmn fr us t see patients d well fr several years It is ur bservatin that patients with spinal stensis, especially assciated with limb pain, d better than thse with herniated discs. It is ur bservatin that Sacriliac injectin typically nly prvides weeks t mnths f relief, at best. Page 9 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301

10 The unfrtunate reality is that there are n predictive variables fr wh will d well and wh wn t with epidural injectin. The cst/benefit rati favrs using epidural injectin befre spine surgery as a treatment mdality when ther cnservative measures have failed, when there is a significant limitatin f functin due t pain, and when there is n prgressive neurlgic deficit. Page 10 f 10 Cncrd Orthpaedics, P.A. 264 Pleasant Street Cncrd, NH 03301