I have been practicing interventional pain management for over 20 years, and over that time have treated thousands of patients. Many of these patients have had previous injections that failed. I have over the years developed what I feel are tried and true diagnostic protocols and therapeutic techniques.
I recently posted on my social media information concerning patients who failed to improve from stem cell therapy. In this article, someone with spinal stenosis underwent stem cell therapy, which frankly is in my opinion a condition which cannot be helped with such regenerative therapy. One of the points this article made is that patients who are suffering from chronic back pain are desperate for relief.
Pain management therapies can help many patients with a wide range of spinal conditions. These are appropriate for anyone who suffers from back pain for a time and who have failed more conservative modalities.
The following are my basic treatment protocols for the most common spinal conditions. The overall goal is to treat the condition with minimally invasive interventional therapies and avoid more aggressive interventions including surgery.
There are a multitude of possible causes of neck and low back pain. The structures in the neck and back include the intravertebral discs, facet joints, exiting spinal nerves, and supporting structures including various muscles and ligaments. Most people undergo an MRI study as part of their diagnostic work up. This is important and necessary. However, it is well known that MRIs may be inaccurate over 40% or more of the time. Therefore, basing treatment on the results of the MRI can fail almost half the time. The most important point of this article is that one injection may not work, and that it may be necessary to undergo a series of treatments, and not to give up on pain management too soon.
If I feel that a patient’s symptoms are due to a disc herniation, then the treatment of choice is an epidural steroid injection. There are two types of epidural injections, an interlaminar and a transforaminal (nerve root) injection. Medication in an interlaminar injection is placed posterior, and can bath multiple disks at once. A nerve root injection, as the name suggests, places the medication directly at the level of the nerve impingement. If a majority of the pain is localized to the back, then I will usually try an interlaminar epidural injection first. However, if the pain radiates into the lower extremity (ie. lumbar radiculopathy), I perform a transforaminal epidural injection. However, as stated earlier, you should not give up if benefit is not initially achieved. A least two epidural injections may be necessary, but should this fail, other injections should be trialed. In such cases, other treatments may include facet injections if the pain is localized to the low back, sacroiliac joint injections, or trigger point injections. Lastly , a diagnostic lumbar discography may be warranted in refractory cases. The results of the discography will determine if a percutaneous disk decompression procedure may be beneficial.
Facet Joint Arthropathy
The next most common spine condition is facet joint arthropathy. The signs and symptoms of this condition can be found in my website. The treatment for this is a diagnostic facet medial branch block. If the medial branch block brings temporary benefit, then a radiofrequency ablation (AKA rhizotomy) is warranted. In most cases this will provide long-term relief. Any residual symptoms may be treated with trigger point injections if I feel residual muscle pain exists.
Pain from the sacroiliac joints is probably the one of the most common but also one of the most underdiagnosed conditions causing low back pain. A simple diagnostic-therapeutic anesthetic block is all that is needed to confirm this condition. In many cases one or two treatments is all that is needed to permanently alleviate the condition. However in refectory cases, I perform Radiofrequency Ablation to achieve permanent relief. There may be some residual myofascial component for which trigger point injections will be beneficial. This injection should also be tried after failed facet injections, as low back symptoms can be almost identical.
Spinal stenosis is narrowing of the spinal cord due to age related changes in the spine. The classic symptom is called neurogenic claudication, which is leg pain that occurs during walking. Epidural steroid injections are the first line treatment. However, if this fails, relatively new procedure called MILD, minimally invasive lumbar decompression, can be beneficial. This is an alternative to surgery, which usually involves a multilevel lumbar laminectomy. The MILD procedure uses a trocar like device to remove some of the internal tissue and bone causing the stenosis through a small (one inch) incision. Lastly, spinal cord stimulation is another treatment option for patients wishing to avoid surgery. https://www.youtube.com/watch?v=y9bzth9b2FY&t=9s
Sciatica is a descriptive term meaning lower extremity pain. However the cause is usually a pinched nerve in the back. However, there are many other causes of back pain which can produce pain down the legs. A diagnostic selective nerve root block will help confirm the ideology, and may provide long term benefit. However, if benefit is not achieved, other causes should be evaluated. These can involve any of those already discussed.
Myofascial Pain Syndrome
Myofascial Pain Syndrome is another name for lumbar sprains and strains. Muscular and ligament injuries can be primary (the sole source of the pain), or secondary to any other spinal condition. Despite the fact that many patients with such sprains can resolve on their own, or with physical therapy, many do not. Treatment involves simply office based injections of anesthetic into the muscle. Long term benefit can be achieved after one or a series of treatment.
Post Surgical Pain Syndrome
Unfortunately many patients have persistent pain despite “corrective surgery”. The reasons why surgery may fail are complex. Treatment must involve going back to the drawing board. I’ve had patients benefit from simple trigger point injections into the scar tissue, facet or sacroiliac join t injections, or epidural steroid injections. In patients who fail these treatments, there also exist implantable devices such as spinal cord stimulators and spinal infusion pumps.