Your comfort during these procedures is important to us. We will ensure that all questions are answered and the purpose of each procedure is clearly explained.

The following are protocols for specific areas of pain treatment:

Trigger Point Injections

Trigger point injections can be a simple and effective option for treating pain for some patients. We use this technique to treat discreet areas of muscle spasm or "trigger points." These knots of muscle form when muscles do not relax. You feel pain because the trigger points may irritate the surrounding nerves. These knots in the muscle are easily detected just beneath the skin. They are firm or hard painful areas in the muscle. Palpation or pressure over the area can aggravate your pain and cause muscle twitching and radiating pain.

When Is Trigger Point Injection Used?
This procedure is used to treat affected muscle groups: most often in neck, shoulders, upper and lower back. However, we have used this procedure in places like the head to relieve tension headaches, with very good results. In addition, trigger point injections can be used to treat diffuse conditions such as fibromyalgia and myofascial pain syndrome that have not responded to other treatments.

The Procedure:
During the procedure Dr. Carpentier will begin by inserting a small needle into the painful trigger point. This needle is generally of very fine caliber. Medications will be injected to numb the area of muscle spasm and relieve the constant muscle contraction resulting in the painful trigger point. This takes only a few minutes and often there is sustained relief. We can inject multiple sites in a single office visit. It may be necessary to perform serial injections over several office visits. This procedure carries very low risk and can safely be repeated as often as necessary.

The procedure is causes minimal pain and the relief is often instantaneous and dramatic. Medication injected is usually a small amount of Bupivacaine or Lidocaine. Occasionall a small dose of glucocorticoid is also injected. Occasionally, we find that simple "dry needling" can accomplish the same result.

Sacroiliac Joint Injections (Diagnostic)

The SI joint or Sacroiliac joint is formed at the junction of the Sacrum or tailbone and the Ilium, which is a large wing shaped bone that contributes to form the pelvis. It is a true mobile joint with a synovium. It can be the source of pain in the low back or buttock and can produce radiating pain into the upper leg. This area is often overlooked as a source of low back pain, but can be treated once the diagnosis is established.

When Is Sacroiliac Injection Used?
Sacroiliac joint injections are commonly used to help diagnose the cause of back pain, particularly pain that persists or develops after low back or lumbar spinal surgery. This procedure can eliminate pain temporarily by using a local anesthetic medication to numb the joint, the ligaments, and capsule around the joint. If the joint is injected and your pain goes away temporarily, then it is very likely that the joint is the source of your pain. Once Dr. Carpentier understands the cause of your pain, he will discuss your treatment options with you.

The Procedure:
This procedure is generally performed in a surgery center or procedure room under sterile conditions with live fluoroscopic X-ray to help localize needle placement and ensure medication delivery to the desired area.

An IV will be placed, which allows Dr. Carpentier to quickly administer medications and provide fluids, if needed. You will be brought to the procedure room and asked to transfer onto the procedure table lying flat on your abdomen. The doctor will monitory your heart rate, blood pressure and blood oxygenation.

Using a fluoroscopic x-ray to guide him, the joint is identified. Local anesthetic is injected into the soft tissues overlying the joint to reduce any pain from the procedure. A specialized needle is then inserted into the joint with "live" fluoroscopic X-ray. Once placement is confirmed with multiple X-ray views, a small amount of water soluble contrast is injected into the joint to demonstrate spread within the joint space. Then a small amount of local anesthetic and possibly glucocorticoid is injected into the joint. The needle is removed and the patient is taken to the recovery room. The entire procedure takes about 5 minutes. Relief is almost immediate.

Afterwards, you will remain in a recovery area to make sure you do not have any reaction to the medications.

You will be asked how you feel to measure the effectiveness of the procedure. Beyond that point it will be important to keep track of your pain relief. You will be asked to keep a pain diary for the remainder of the day and report any relief or lack of relief you experience for the remainder of the day.

You will be contacted by the office a day or two following the procedure to evaluate your response and address any questions or concerns. You will be asked to bring your pain diary to the next scheduled office visit. This injection is primarily a diagnostic injection. The pain relief you experience may only be short lived, but the information gathered will help guide long term treatment recommendations.

Peripheral Joint Injections

Peripheral joints are found in the extremities from the shoulders to the fingers and from the hips to the toes. These joints allow for mobility between the bones of the skeleton. Occasionally these joints can become painful from a variety disease states. Joint injections are both diagnostic and therapeutic. This means that the injection can not only tell us from where the pain is generated, but it can also provide pain relief, sometimes for sustained periods.

When Is Peripheral Injection Used?
Peripheral joint injections are usually used to treat painful joints in the shoulders, hips, knees or elbows, wrists, ankles fingers and toes. Joint pain can be caused by bursitis, tendonitis, or arthritis, or soft tissue injuries such as rotator cuff tears or other intrinsic damage to the joints. These disorders may be acute or chronic in nature. A variety of medications can be injected from local anesthetics such as Bupivacaine and Lidocaine for diagnostic purposes, to glucocorticoid, botulinum toxin or hyaluronic acid/viscosupplementation for longer term relief.

The Procedure:
This procedure is performed in the office. Generally no fluoroscopic guidance is required, although occasionally ultrasound guidance may be used to ensure needle placement within the joint capsule. Once the joint in question is identified, the skin is cleansed in a sterile fashion and the soft tissues are anesthetized with local anesthetic to reduce the pain of the actual joint injection. A diagnostic injection is performed initially with local anesthetic and occasionally a small dose of glucocorticoid. If the pain relief is not long lasting, the injection can still be helpful in helping us determine the source of your pain and pointing us in the direction of likely successful long term treatment. Additional injections can be performed with prolonged relief between each injection. Occasionally we recommend the injection of other substances to improve long term pain relief.

Epidural Injections

The following describe epidural injections, which are used to help provide pain relief caused by nerve root irritation and to compliment a patient's progress with their rehabilitation. There are 2 main steroid injection approaches: Transformational and Translaminar or Interlaminar.

The epidural space is a potential space contained within the bones that make up the spinal column, but outside of the sac contains the spinal fluid, spinal cord and spinal nerves. It is bordered posteriorly by the ligamentum flavum and anteriorly by the Dural membrane. It contains fat and blood vessels as well as connective tissues and surrounds the entire inner surface of the spinal column. Injection of medications into this space allows for close contact and easy diffusion of medications to the spinal nerves. The approach is used for both pain relief from back pain and sciatica as well as pain from the neck down resulting from inflammation of spinal nerves. It can also be used for surgical anesthesia for a variety of abdominal, pelvic and lower extremity surgical procedures such as arthroscopic knee surgery or labor and delivery or cesarean section delivery.

Epidural steroid injections (ESIs) have been endorsed by the North American Spine Society and the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research) of the Department of Health and Human Services as an integral part of nonsurgical management of radicular pain from lumbar and cervical spine disorders. They have been evaluated and found to be effective by the evidenced based medicine site Bandolier at the Oxford Pain Internet site and have been shown to be effective in both the short term and long term management of radicular symptoms resulting from intervertebral disc herniation.

Translaminar Epidural Steroid Injections

When Is Translaminar Injection Used?
The interlaminar or translaminar approach is used when there are diffuse areas of disc degeneration that may be too difficult to effectively treat using the more precise Transforaminal approach. It is also used when the intention is to place a catheter into the epidural space when providing surgical analgesia or anesthesia.

The Procedure:
An epidural steroid injection usually takes between 5 and 10 minutes. An IV is placed in order to provide fluids and any required sedation. You will be asked to lay flat on an x-ray table on your abdomen and your back or neck will be prepped in a sterile fashion in the same way as if you were to undergo an open surgical procedure. The doctor will monitor your heart rate, pulse and blood pressure. Your skin and soft tissues will be anesthetized with local anesthetic. Dr. Carpentier will use fluoroscopy for guidance during the procedure. In that case, he will direct a needle toward the epidural space.

Once the needle is in the targeted position, contrast is usually injected. Following confirmation of needle placement and medication flow, a non particulate glucocorticoid and possibly a small dose of local anesthetic will be injected into the epidural space. Fluoroscopy will be used continuously to monitor the flow of injectate to the desired area. You may feel some pressure on your spine or possibly some reproduction of your radicular pain, but this will only last a short time. The needle is then removed and you will be taken to the recovery room. Following the injection, you will be monitored in a recovery room until it is safe for you to return home, usually within 15 to 30 minutes. Sedation is an option for patients who have anxiety and discomfort.

We ask that you rest on the day of your injection. A full post procedure instruction sheet will be provided in the recovery room. In most cases you can resume normal activities the following day.

You will be contacted by our office in the following day or two to ask how you are feeling and to make sure you did not experience any undesirable side effects. You will be asked to keep a pain diary following the procedure so that the results of the procedure can be discussed at the follow up office visit.

Transforaminal Epidural Steroid Injections

When Is Transforaminal Injection Used?
The transforaminal approach has been found to be the most effective way to perform the epidural steroid injection. Its limitations are that medications are placed in very specific locations and tend to treat only one or two nerve roots at a time. Occasionally more than one injection must be employed to satisfactorily treat all affected areas. It is also often used as a diagnostic tool when the source of the pain has not yet been determined. Local anesthetic can be injected directly onto the nerve root and if pain relief is achieved, it provides some evidence that the nerve root injected may be causing the pain. Nerve roots exit the spinal canal and enter the body through small openings between the vertebrae called the foraminae. Doctors inject contrast and a mix of glucocorticoids (steroids) in the area around a selected nerve root between the foraminae to determine if that nerve is, in fact, the cause of the pain as well as to treat any inflammation causing the pain. This type of injection is most commonly used in the lumbar spine region.

The Procedure:
An IV will be placed and you will be brought to the procedure room. You will be asked to transfer from the gurney to the procedure table where you will be placed flat on your abdomen.

The doctor will monitor your pulse, heart rhythm and blood oxygenation during the procedure. Your back or neck will then be prepped in the same fashion as if you were to undergo an open surgical procedure. The soft tissues overlying the epidural space will be anesthetized locally. Dr. Carpentier will insert a small needle into the appropriate area of your spine and inject a small amount of water soluble contrast to ensure flow of medication into the desired areas. Then a small dose of glucocorticoid or steroid and possibly local anesthetic will be injected into the nerve foramen. You might feel some pressure in your spine, or reproduction of your pain for a very short time.

After the needle has been withdrawn, the technician will wash your back and apply a bandage. You will then be taken to the recovery area where a nurse will monitor your vital signs for 15 to 30 minutes. Once this monitoring is completed, your IV will be removed and you are free to go home.

You will be encouraged to rest for the day. You can usually resume normal activities the following day. If this was intended to diagnose the source of pain, you will be asked to keep a pain diary for the remainder of the day.

Our office will call you two days after the procedure to ask questions about how you are feeling and to ensure that you did not experience any negative side effects from the injection. You will be asked to bring your pain diary with you to review during the scheduled follow up visit.

Facet Medial Branch Injections

The facets are joints on the posterior spine, or the back of the spinal column, which allow for mobility of the motion segment. The motion segment is comprised of a vertebral body, an intervertebral disc and the mobile portion of the facet joints from two adjoining levels of the spine. They allow for mobility when we flex forward, extend backward or when we rotate or lean to the left and right. These joints can often become painful after degenerative changes occur. The pain of facet joints tends to worsen with activity and improve with sitting down, or leaning forward against a counter or grocery cart while standing. It is generally most severe in the morning and at the end of the day. It seems to improve for a little while when we get up and get moving in the early part of the day. The quality of the pain is aching and stabbing in nature. It can occasionally be burning.

The nerve that innervates the facet joint is the medial branch. It can be anesthetized locally in order to determine if the pain is mediated by the joint in question. If local anesthetic successfully relieves the symptoms of back pain, then a technique such as radiofrequency rhizotomy can be employed to provide prolonged and sustained pain relief.

When Are Medial Branch Injections Used?
Dr. Carpentier may order a facet or medial branch block if you have pain primarily in your back that is associated with arthritic changes in the facet joints and pain that worsens with motion or activity and is improved with rest. The procedure can be used to diagnose and treat facet joints anywhere along the spine from the base of the skull to the tailbone.

A facet block or medial branch block is generally used as a diagnostic tool, but can also be a treatment for your condition. Once the procedure is performed the doctor will ask you to keep a pain diary to determine if the pain is relieved and if so, for how long. If the pain goes away for a few hours but then returns, the doctor will conclude that the pain is likely coming from the facet joints.

Depending on your reaction and the number of joints involved, you may require multiple injections at one sitting and may require a second visit for a repeat procedure.

The Procedure:
An IV will be placed. You will be taken to the procedure room and instructed to lie on your abdomen on an X-ray table. Dr. Carpentier will use a live x-ray, or fluoroscopy for guidance. Needles will be placed on the appropriate medial branches. Once the doctor has identified the proper location, local anesthetic (with or without steroid) is injected directly onto the nerves innervating the joint. If the injection is beneficial, the procedure can be repeated.

You will be taken to the recovery room and monitored for 15-30 minutes. After discharge, you will be instructed to keep a pain diary for the remainder of the day and report back with the duration of the pain relief if any. You will be encouraged to be as active as usual for the remainder of the day.

Our office will call you two days after the procedure to ask questions about how you are feeling and to ensure that you did not experience any negative side effects from the injection. You will be asked to bring your pain diary with you to review during the scheduled follow up visit.

Peripheral Nerve Blocks

The peripheral nerves are the nerves outside of the brain and spinal cord that transmit sensation and supply motor (movement) control.

When Are Peripheral Root Blocks Used?
When the nerves are damaged by trauma, surgery, scar tissue, or illness, anesthetic blocks of peripheral nerves can help provide diagnosis and relief. Here are three examples of common peripheral nerve blocks:

• Occipital nerves travel from the cervical spine in the neck to the back of the head and scalp. They can be damaged by arthritic changes in the cervical spine, muscle spasm, or whiplash type neck injuries. Sometimes, as a result, headaches can begin in the back of the neck and spread towards the forehead and behind the eye.
• Occipital nerve blocks with steroids can often help to relieve the symptoms of occipital nerve pain or occipital neuralgia. If the relief is not lasting, Radiofrequency lesioning can be employed, as can injection of botulinum toxin or even placement of a peripheral nerve stimulator.

• Intercostal nerves: Surgeries and chest injuries can injure the intercostal nerves, leading to chronic chest pain.
• A valuable part of the treatment may be to block or anesthetize these nerves. Occasionally a technique called Pulsed Radiofrequency lesioning can provide lasting benefit. Spinal cord and peripheral nerve stimulation can also be beneficial, as can the use of a cold probe, called cryoablation.

• Ilioinguinal nerves: These wrap around the rim of the pelvis and lead to the groin and pubic areas. Surgeries or scar tissue following hernia repairs and cesarean sections can cause injuries to this nerve and pain in the distribution of the nerve.
• Nerve blocks may be the best treatment. Medications such as local anesthetic and steroid can be employed, as can Pulsed Radiofrequency lesioning and peripheral nerve stimulation, or cryoablation.

The Procedure:
These procedures can often be done in the office. Occasionally an ultrasound imaging machine will be employed to help localize the target nerve. A fluoroscope can also be used to help identify appropriate needle placement. A nerve block needle is inserted in the vicinity of the targeted peripheral nerve. A dose of local anesthetic and glucocorticoid is injected. Other treatments can be employed as described above if the injection successfully relieves the painful symptoms.

You will be encouraged to resume normal activities following the procedure. No period of rest is required. You will be asked to keep a pain diary and record the duration of pain relief for the remainder of the day following the procedure and bring it with you to the scheduled follow up visit.

Racz Procedure

Epidural Adhesiolysis or the "RACZ" procedure is used to break up some of the scar tissue around entrapped nerves in the spine so that medications like cortisone can reach the affected areas. It is named after the pioneer of the procedure, Gabor Racz.

When is the Racz Procedure Used?
When Dr. Carpentier wants medications to reach specific affected nerves which are blocked by scar tissue, he'll use this procedure. The procedure is typically employed following spine surgery which fails to relieve back pain and radiculopathy. A specialized spring tipped catheter is used to gently push away scar tissue and obstruction which may otherwise prevent injected steroid or other medications from reaching the target tissues. The procedure is used when other more conventional epidural steroid injections fail to provide relief in the setting of previous spine surgery.

The Procedure:
The procedure requires only a few minutes:

• First, a catheter is inserted into the epidural space up to the area of scarring. This is done in the operating room under sterile conditions using an x-ray called fluoroscopy. Local anesthetic and sterile saline is injected along with small doses of water soluble contrast while the catheter is inserted and maneuvered to clear away obstructing scar tissue.
• Hyaluronidase and hypertonic saline are used to help break up scar tissue and provide pain relief. Glucocorticoid is used as an anti-inflammatory, once it is clear from the position of the catheter and the flow of the water soluble contrast as visualized on fluoroscopy, that the medications are reaching the target tissues.

You will be encouraged to resume normal activities following the procedure. No period of rest is required. You will be asked to keep a pain diary and record the duration of pain relief for the remainder of the day following the procedure and bring it with you to the scheduled follow up visit.

Discography

Discography is a technique for visualizing the morphology of the intervertebral disc and for evaluating whether or not the disc in question is a "pain generator." The technique involves inserting a thin needle into the intervertebral disc under fluoroscopic guidance. Once the needle is in place, specialized equipment is used to deliver precise volumes of water soluble contrast into the disc in order to evaluate its appearance and whether or not pain can be reproduced with pressurization of the disc.

When we examine other parts of the body, such as the abdomen, an important part of the exam is palpation or "feeling" the abdomen with our hands. A great deal of information can be learned from the way the organs feel under the skin as well as from how the patient responds to our prodding. We are unable to actually palpate an intervertebral disc because of its location inside the body. We use a needle and X-ray as well as observation of what the patient reports as their experience to effective "feel" the disc.

When is Discography Used?
Discography is used to help the surgeon determine the source of back pain. The pain of a degenerative disc causing pain is often described as aching, dull, nagging pain which is worsened with prolonged sitting primarily, but can be worsened by remaining in a position for prolonged periods of time. Patients with discogenic pain (pain eminating from the intervertebral disc) often report they need to shift positions in order to gain relief, but the relief only lasts minutes, before they have to shift again. The pain is felt to be caused by contents from the central part of the disc leaking onto the surrounding nerves both in the outer annulus of the disc as well as onto the surrounding nerve roots. Pain which is aggravated by discography helps point to the disc as a source for the patient's back pain symptoms. Conversely, pain that is not aggravated by discography is a good indicator that the disc is not the source of the pain.

The Procedure:
You will be brought to the procedure room and placed in the appropriate position for the procedure that will be performed. You will be positioned on your back for cervical discography and on your abdomen for thoracic and lumbar discography. Your skin will be carefully prepped and draped as if you were to undergo open surgery. We will carefully monitor your heart rate, pulse and blood pressure. You will be given intravenous anesthesia to help reduce the pain from the procedure, but you will not be "knocked out." Instead, you will be aware of what is happening for the entire procedure. Local anesthesia will be inserted into the center of the disc in question. Once the needle is properly placed, a water soluble contrast is injected into the disc using a specialized syringe and pressure monitor. Your response to the injection is compared to the volume of contrast injected and the appearance of your disc on X-ray. If pain comes on that is similar to your existing back or neck pain, it will suggest that the disc might the source of your pain. Each disc needs to be tested separately with a separate needle placement.

You will be encouraged to resume normal activities following the procedure. No period of rest is required. You will be asked to keep a pain diary and record the duration of pain relief for the remainder of the day following the procedure and bring it with you to the scheduled follow up visit.

Radio Frequency Lesioning/Pulsed Radio Frequency Lesioning

When is Radio Frequency Rhizotomy Used?
When the doctor wants to decrease and/or eliminate pain symptoms arising from painful nerves within the spine or periphery, he'll use this therapeutic procedure. It involves destroying the nerves that innervate the facet joints with highly localized heat generated with radiofrequency. By destroying these nerves, the body has no method of linking pain signals from the spine to the brain. A similar effect may be achievable with Pulsed radiofrequency rhizotomy. In this technique, the same type of needle and probe are placed on the affected nerve, but instead of creating a heat lesion, normothermic (or body temperature) radio frequency energy is delivered to the nerve to effectively "turn it off" for a period of time.

The Procedure:
Once Dr. Carpentier had confirmed where your pain originates, by using one of the procedures described above for nerve blocks, epidural injections, facet blocks, etc., a radiofrequency lesioning may be offered to provide sustained or long term pain relief.

During the procedure:

A thin needle electrode is placed near the nerve determined to be the source of the pain. The doctor may use fluoroscopy to guide the needle. Or, an ultrasound may be employed, or the needle can be located simply by "stimulating" the nerve using the built in nerve stimulator employing very low energy electricity. Its position will be very carefully confirmed using sensory and motor stimulation as well as X-ray images or ultrasound if necessary. The doctor will then inject an anesthetic directly onto the nerve. A lesion will then be created on the nerve employing either thermal or non thermal radiofrequency energy. While this procedure doesn't typically "destroy" the nerve, it can eliminate its ability to transmit painful signals for a prolonged period of time lasting anywhere from 6 months to a year. This procedure is then repeated at each nerve as needed. It can also be repeated if the pain recurs.

After the procedure:
The nurse will review with you how you should take care of yourself. Numbness and/or relief from symptoms for 2-8 hours after the procedure is normal due to the anesthetic. It is also common for your usual symptoms to return once the local anesthetic effects have worn off. They may be more severe for up to 5-7 days after the procedure. This is called neuritis and it occurs as the nerve is in the process of "shutting down." It generally takes 2-3 weeks to reach maximum improvement.

You will be contacted by the office staff in the first couple of days following the procedure to be sure all your questions are answered and to make sure there were no problems that need to be addressed. You will be asked to keep a pain diary and record the duration of pain relief following the procedure and bring it with you to the scheduled follow up visit.

Nucleoplasty

When is Nucleoplasty Used?
Nucleoplasty is performed after a discogram has successfully identified the source of the pain as a painful disc in the lumbar spine. It is used when the disc height is well preserved and there is no obvious compression of nerves in the spine on MRI. It is limited to the treatment of two painful discs.

The Procedure:
You will be brought to the procedure room and placed in the appropriate position for the procedure that will be performed. You will be positioned on your back for cervical discography and on your abdomen for lumbar discography. Your skin will be carefully prepped and draped as if you were to undergo open surgery. We will carefully monitor your heart rate, pulse and blood pressure. You will be given intravenous anesthesia to help reduce the pain from the procedure, but you will not be "knocked out." You will be aware of what is happening for the entire procedure. The skin with be anesthetized locally and a needle will be inserted into the center of the disc in question. Once the needle is properly placed, a specialized procedure probe will be placed into the disc nucleus. Using a specialized Coblation energy delivered through the probe, disc nuclear tissue is then removed by either creating channels (lumbar spine) or spheres (cervical spine). After the targeted tissue is removed, the needle and probe are removed. A bandage is placed on the skin and you will be taken to the recovery room for 15-30 minutes prior to being discharged home.

Intradiscal Electrothermoplasty (IDET)

When is IDET Used?
People with discogenic back pain are candidates for this procedure. IDET is performed after a discogram has successfully identified the source of the pain as a painful disc in the lumbar spine. It is used when the disc height is well preserved and there is no obvious compression of nerves in the spine on MRI. It is limited to the treatment of two painful discs.

The Procedure:
You will be brought to the procedure room and placed on your back for cervical discography and on your abdomen for lumbar discography. Your skin will be carefully prepped and draped as if you were to undergo open surgery. We will carefully monitor your heart rate, pulse and blood pressure. You will be given intravenous anesthesia to help reduce the pain from the procedure, but you will not be "knocked out." Instead, you will be aware of what is happening for the entire procedure. The skin with be anesthetized with local anesthesia and a needle will be inserted into the center of the disc in question. Once the needle is properly placed, a specialized procedure probe will be placed into the annulus of the disc, or position just inside the annulus. This probe will be positioned so that the thermal edge is located along the posterior margin of the disc against the areas of fissure identified in the disc with discogram and the post discogram CT. Thermal energy is then transmitted, which destroys the small nerve fibers that have grown into the cracks and have invaded the degenerating disc. These nerves are felt to be the major source of discogenic pain. The heat also causes the proteins in the disc to contract which may cause the disc bulge to retract and the cracks in the annulus to "seal up." Pain relief occurs in the first few days. You will be taken to the recovery room for monitoring for 15-30 minutes. You will then be discharged to home.

You will be contacted by the office staff in the first couple of days following the procedure to be sure all your questions are answered and to make sure there were no problems that need to be addressed. You will be encouraged to rest following the procedure. A specific recovery program will be prescribed. You will begin with simple exercises and gradually increase your activities in a carefully prescribed manner. You will be asked to keep a pain diary and record the duration of pain relief following the procedure and bring it with you to the scheduled follow up visit.

Vertebroplasty / Kyphoplasty

As bones of the spine age they can weaken. If it is stressed enough, the bones can form cracks or fractures. These fractures can be a significant source of pain. The pain is generally mechanical in nature, meaning that it worsens with activity and improves with rest. These fractures can be visualized on X-ray and CT and sometimes MRI. If they are acute or new, and causing pain, it is possible to stabilize them with a technique called vertebroplasty/Kyphoplasty. With this technique, the fractured areas can be stabilized using a needle to inject methylmethacrolate or other bone cement. The cement acts as glue to hold the pieces together and thus reduces the pain that occurs when the fractures shift. It is most effective with acute or fresh fractures, so additional evaluation such as a radionuclide bone scan may be warranted to be sure the fractures identified are new. The procedure is typically used for a spine fracture caused by osteoporosis, a disease that causes weakening of the bones and can lead to fractures in the vertebral bodies (those bones that make up the spinal column). An osteoporotic fracture can cause extreme back pain along with other symptoms, such as decreased height and spinal deformity or a hunchback appearance.

When is Vertebroplasty Used?
This is used to reduce pain caused by compression fracture in the spine. It is a minimally invasive procedure and patients usually go home the same day.

The Procedure:
An IV will be placed in the holding area. This will be used to administer fluids and sedation to keep you comfortable during the procedure. You will be brought to the procedure room and placed on your abdomen. Your back will be prepped in a sterile fashion just as if an open surgical procedure were to be performed. A live X-ray or fluoroscopy will be used to identify the Pedicle of the vertebral body in question. The soft tissue overlying the bone will be anesthetized locally. A specialized needle will be advanced into the vertebral body and positioned at the area of the fracture. Bone cement will then be injected into a fractured vertebra in order to stabilize it. Once the injection is completed, the needle will be removed and you will be taken to the recovery area for observation. You will generally be discharged within an hour or so.

When is Kyphoplasty used?
Kyphoplasty differs from vertebroplasty in that rather than simply injecting the bone cement, the vertebral body is first expanded using a specialized balloon in an effort to restore more normal height to the compressed and fractured vertebral body. It is often employed when the vertebral body is deformed enough that it alters the normal physics and mechanics of the spine.

From the patient standpoint, the procedure is almost identical to vertebroplasty with the preparation and recovery from the procedure being the same. It can require slightly longer surgical times to inflate the balloon to restore the height of the vertebral body and to possibly inject larger volumes of bone cement.

The risks from the two procedures are roughly the same. The recovery period and post operative courses are also similar.

You will be contacted by the office staff in the first couple of days following the procedure to be sure all your questions are answered and to make sure there were no problems that need to be addressed. You will be encouraged to rest following the procedure. A specific recovery program will be prescribed. You will begin with simple exercises and gradually increase your activities in a carefully prescribed manner. You will be asked to keep a pain diary and record the duration of pain relief following the procedure and bring it with you to the scheduled follow up visit.

Spinal Cord Stimulators

Spinal Cord Stimulators were developed in the 1960's to treat neuropathic, or nerve injury pain. They have been gradually improved over the decades to their current form. They utilize pacemaker battery technology and small electrodes to effectively relieve the pain from a variety of painful conditions. They require surgical implantation and are generally performed in two stages. The first stage or trial is performed by placing a specialized needle into the epidural space in the spine and then guiding an electrode through the needle using live X-ray or fluoroscopy. The patient is awake during the procedure as precise placement requires feedback from the patient to determine optimal positioning. Once the lead is positioned in the appropriate place, the needles are removed and the patient is able to "test drive" the stimulator to determine whether or not it is effective at relieving pain. Following the trial, the leads are removed in the office and it will be determined if permanent implantation is appropriate.

Permanent implantation requires surgery to fasten the leads to the spine and to create a pocket under the skin to contain the pulse generator, or power source for the electrodes. A connection between the generator and electrodes will also be made beneath the skin so the entire system is hidden beneath the skin when the procedure is completed. Recovery from this surgical procedure generally requires about a week.

When are Spinal Cord Stimulators Used?
Spinal Cord Stimulators or Dorsal Column Stimulators are implantable medical devices used to treat chronic pain in the trunk and limbs. An electric impulse generated by the device near the dorsal surface of the spinal cord provides a "tingling" sensation that alters your perception of pain. The device can excite descending inhibitory fibers that effectively blunt the painful sensations being transmitted to the brain. The technique is most effective for treating nerve injury type pain from Failed Back Surgery Syndrome, RSD, or other peripheral nerve pains. It is less effective for treating neck and back pain, but newer technologies are allowing for pain relief in these areas as well for some patients.

There are three types of Spinal Cord Stimulators:

A radio frequency device is simple and has an implanted receiver and a transmitter that you wear. The transmitter sends signals to the receiver which then sends stimulation to the lead. These units have traditionally been used for patients that require high-power settings that would quickly deplete a primary-cell implantable pulse generator. A Conventional Implantable Pulse Generator has a primary cell battery and control electronics. When the battery is depleted, it is surgically replaced for you. A Rechargeable Implantable Pulse Generator carries a rechargeable battery and control electronics. The battery is recharged by an external device worn every two to three weeks for a few hours. This type of device has largely replaced the Radio Frequency device and primary cell technology described above.

The Procedure:
An IV will be placed in the holding area. This will be used to administer fluids and sedation to keep you comfortable during the procedure. You will be brought to the procedure room and placed on your abdomen. Your back will be prepped in a sterile fashion just as if an open surgical procedure were to be performed. A live X-ray or fluoroscopy will be used to identify the target area in the spine for needle placement. The soft tissues will be anesthetized and a specialized epidural needle will be placed. Dr. Carpentier will then introduce the spinal cord stimulator lead into the epidural space via the needle. The lead will be positioned at the appropriate level of the spine based on the pain complaint and a trial of stimulation will commence. The lead will be adjusted using Fluoroscopy until the tingling sensation covers all painful areas. The needles will then be removed and the leads will be left in place. You will be provided with an external power supply and control device so that you may operate the stimulation at your leisure. You will be instructed in the use of the device in the recovery area and will have close contact with representatives of the device manufacturer for the duration of the trial, which usually lasts 5-7 days. You will be instructed about activities to avoid during the trial period such as bathing, bending, stooping, overhead work, etc. A complete instruction sheet will be provided. You will be given a prescription for antibiotics which you will take for the entire duration of the trial.

When the trial stimulation period is completed, the leads will be removed in the office or surgery center. The removal of trial leads is no more complicated than removing an IV from your hand. It is not painful and takes a few seconds. You will then be asked about the effectiveness of the device. If you meet criteria for permanent implantation based on pain relief and functional improvement, you will be able to undergo permanent implantation.

Permanent implantation requires one or two incisions. The procedure is carried out much in the same way as the trial, except that an incision will be made over the spine and carried down onto the spine before the needles are advanced into the epidural space. This is so that the leads can be securely anchored to the spinal column in order to reduce the risk of lead movement or migration over time. Once the leads are properly positioned as they were in the trial, they will be sewn in place. A second incision may be made in order to create a pocket under the skin to accommodate the IPG or battery, depending on where you elect to have the battery placed and other surgical considerations. A connection between the two incisions will be made in order to connect the leads to the IPG. The wounds will be closed surgically and you will be taken to the recovery room. The procedure is generally performed as an outpatient procedure and you will be discharged home after an hour or so in the recovery room. You will again be instructed on the use of the device in the recovery room. You will be given a complete instruction sheet in the recovery room. You will be given a prescription for antibiotics which you will take for a course of 7 days following the surgery

Our office will call you two days after the procedure to ask questions about how you are feeling and to ensure that you did not experience any negative side effects from the injection. You will be asked to bring your pain diary with you to review during the scheduled follow up visit in a few days.

Peripheral Nerve Stimulators

Peripheral Nerve Stimulators are identical to the devices used in spinal cord stimulation. The electrodes are placed over nerves in the scalp, trunk, arms, abdomen, back, pelvis or legs to relieve the pain from specific nerve injury. The technique is very similar for nerve block procedures described above except that rather than injecting medications only, a stimulator electrode is placed next to the nerve using stimulation just as in the placement of spinal cord stimulators. The stimulator can disrupt the painful signals being transmitted from the nerve to the brain and significantly reduce pain. It is only effective to treat pain from injured nerves. The trial and surgical procedures are carried out in essentially the same manner as for spinal cord stimulation. Implantation of permanent stimulators is also very similar except that there is no need to anchor the device directly to the spinal column. Instead, the lead is anchored to tissues near the affected nerve to prevent migration. A similar pocket is created for the IPG.

Intrathecal Drug Delivery Systems

When Is Intrathecal Drug Delivery Systems Used?
Intrathecal drug delivery places medication directly into the cerebrospinal fluid that surrounds the spinal cord and brain. This technique is used selectively in only a few cases to deliver medications directly to the spinal cord and brain in an effort to relieve intractable pain that does not respond to any other treatment method. It is considered a treatment of last resort by most practitioners.

The doctor will use medications injected directly to the spinal fluid and because of the way the body's brain and spinal cord receive medications, much smaller doses are needed than if given IV or orally and the frequency of some side effects can reduced.

The Procedure:
Intrathecal drug delivery places medication directly into the cerebrospinal fluid that surrounds the spinal cord. The doctor will administer medication directly into the spinal fluid -- that is what makes the procedures particularly effective -- because the medication does not have to circulate systemically to reach the intended area in the spinal cord. Also, because of that, much smaller doses are needed and the frequency of side effects are lessened.

If the technique successfully controls pain, then a specialized pump can be implanted under the skin with a small tube or catheter connecting it directly to the spinal fluid. Tiny amounts of medication can be continuously delivered to the spinal fluid and by extension the spinal cord and brain.

The trial period is usually carried out in the hospital. Occasionally a single injection of medication is used for the trial. At other times, a small catheter is placed in the spinal canal and connected to an external pump so that medications can be delivered over days or even weeks. This period can be either outpatient or inpatient, depending on the complexity of the medication regimen and the severity of the pain. There is always a 12-48 hour period of hospitalization to address any potential complications that may arise from the delivery of medications directly into the spinal fluid.