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Treatment provided...
We provide a variety of therapies to aid in the management of pain based on your
needs, including Interventional Pain Medicine, which involves special procedures to
treat and manage pain. Interventional Pain Medicine refers to a group of minimally
invasive surgical procedures typically done as an outpatient to alleviate acute,
chronic, or cancer-related pain conditions. These include, but are not limited to,
trigger point injections, epidural steroids (interlaminar, nerve root, and caudal
injections), facet injections, peripheral nerve blocks, sympathetic blocks (stellate,
lumbar sympathetic, celiac plexus, and hypogastric plexus blocks), intravenous
infusions, neurolytic procedures (radiofrequency lesioning, cryotherapy, and chemical
neurolysis), Botulinum Toxin injections, intradiscal treatments (IDET, Nucleoplasty/
Coblation, LASE), vertebroplasty, and intraspinal analgesics. Dr. Binegar has the
specific training and expertise that is required to perform each of these types of
procedures, as well as the management of potential complications. When indicated,
Dr. Binegar will use flouroscopy (X-Ray) to guide proper placement of the therapeutic
medication.
For persistent pain, not responsive to other types of therapy, consideration may be
given for a spinal cord stimulator or, in select cases; nerves can be destroyed by
chemical means, freezing, or by applying a heat lesion. In addition, a discogram
(injection of dye into the spinal discs) can be used to help diagnose certain types of
back pain.
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The types of pain we treat include:
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Herniated disc |
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Sciatica |
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Spinal stenosis |
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Back conditions |
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Neck problems |
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Chest and abdominal |
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Facet syndrome |
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Discogenic disease |
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Joint disorders |
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Neurological injuries |
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Myofascial syndrome |
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Reflex sympathetic dystrophy (RSD) |
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Complex regional pain syndrome (CRPS) |
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Cancer pain |
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Post herpetic neuralgia/shingles |
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Osteoarthritis |
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Occipital Neuralgia |
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Vertebral Compression Fractures |
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Sacroiliac problems |
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Rib fractures |
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Causalgia |
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Whiplash Injuries |
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Chronic Post-Surgical Pain |
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Other Chronic Pain Diagnoses |
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Epidural steroid injections/interlaminar technique
Epidural injections are typically done for people with radicular pain (i.e., neck/arm pain,
or low back/leg pain). The epidural space is within the spinal canal and extends from
the base of the skull to the sacrum. All the nerve roots course through the epidural
space. Irritation of the nerve roots can be caused by degenerative disc disease,
herniated or bulging disc, spinal stenosis, bone spurs, arthritis, or scar tissue from
prior surgeries. After appropriate anesthetic (usually only subcutaneous local
anesthetic), a needle is placed into the epidural space at the level of the problem
between two vertebrae (interlaminar). Injection of 4-10 cc of a mixture of local
anesthetic/steroid is then placed in the epidural space to bathe the nerve roots at not
just one level but several levels. The local anesthetic quiets the nerves down while the
steroid is to decrease the inflammation of the nerve roots. If an initial injection is helpful,
typically a series of two to three injections is done.
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Nerve root injection/transforaminal epidural
Nerve root injections are a special type of epidural injection referred to as
transforaminal epidural steroid. Instead of bathing several nerve roots as with an
epidural injection, only one nerve root is injected but with a higher dose of steroid.
Often this is done with a far lateral herniated disc and/or foraminal stenosis. It may be
helpful for surgeons for diagnosis of the correct level. Nerve root injections do require
use of x-ray and typically with sedation.
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Caudal steroid injections
Caudal injections are another special type of epidural injection. A caudal approach
requires placing the needle through an opening, the sacral hiatus, near the tailbone to
reach the lower nerve roots of the spine. This approach is most commonly done for
people with prior back surgeries and especially if prior fusion, yet have persistent low
back pain and buttocks pain.
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Facet joint injection
There are two facet joints (one on each side) between every vertebra. Each vertebra is
like a tripod with the front of the vertebra resting on the disc and the back part of the
vertebra resting on the two facets. The facet joints can develop arthritis like any other
joint in the body. Arthritis can occur from trauma, such as with a whiplash injury causing
cervical facet arthritis. However, most often facet arthritis is seen in the lower lumbar
segments, which bears most of the weight. Injection of the facet requires use of x-ray
and typically sedation. The injectate is again a local anesthetic/steroid combination.
As with most steroid injections, if the initial injection is helpful, a series of two to three
injections may be done.
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Stellate ganglion block
A stellate ganglion block is done most often for people with RSD (Reflex Sympathetic
Dystrophy), also called CRPS (Complex Regional Pain Syndrome) of the arms. RSD
may result from an impaired sympathetic nervous system (the fight or flight part of our
nervous system). Typically RSD occurs after an injury, fracture, or surgery to the arm
resulting in a very sensitive upper extremity with vascular changes such as edema
and/or color changes and often decreased range of motion. The stellate ganglia lives
in front of the lower cervical spine on each side of your voice box. Blocking the ganglia
interrupts the sympathetic nervous system in an attempt to “reset” the sympathetic
nervous system. With a sympathetic block, you should not experience numbness or
weakness, however, you should feel a warmth in your extremity. A sympathetic block
allows less pain and better movement of the extremity.
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Lumbar sympathetic block
Lumbar sympathetic blocks are done for people with RSD (Reflex Sympathetic
Dystrophy), also called CRPS (Complex Regional Pain Syndrome) of the legs. RSD
may result from an impaired sympathetic nervous system (the fight or flight part of our
nervous system). Typically RSD occurs after an injury, fracture, or surgery to the leg
resulting in a very sensitive lower extremity with vascular changes such as edema
and/or color changes and often decreased range of motion. The lumbar sympathetic
ganglia live in front of the L2, L3, and L4 vertebrae. Blocking the ganglia interrupts the
sympathetic nervous system in an attempt to “reset” the sympathetic nervous system.
With a sympathetic block, you should not experience numbness or weakness, however,
you should feel a warmth in your extremity. A sympathetic block allows less pain and
better movement of the extremity.
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Celiac plexus block
The celiac plexus innervates the lower esophagus, stomach, small intestines, most of
the large intestines, liver, pancreas, spleen, adrenal glands, and kidneys. Therefore,
by blocking the celiac plexus, you can interrupt the pain fibers from these abdominal
organs. The celiac plexus is actually a series of ganglia just in front of the aorta and
the first and second lumbar vertebrae. A diagnostic block is done first with local
anesthetic only. If the patient has a good response, we then consider proceeding with
a neurolytic block (usually alcohol). This is most commonly done for patients with
pancreatic cancer with upper abdominal pain, but may also be tried for cancer of the
other above listed organs.
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Superior hypogastric plexus block
The superior hypogastric plexus innervates the lower sigmoid colon, bladder, ureters,
testes, and ovaries. Therefore, by blocking the superior hypogastric plexus, you can
interrupt the pain fibers from these pelvic organs. The superior hypogastric plexus is
actually a series of ganglia just in front of the fifth lumbar and first sacral vertebra. A
diagnostic block is done first with local anesthetic only. If the patient has a good
response, we then consider proceeding with a neurolytic block. This is most commonly
done for patients with pelvic cancer with lower abdominal/pelvic pain who are already
incontinent, as one of the significant side effects or complications with this procedure
can be bladder incontinence.
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Trigger point injections
Trigger point injections are done for people with myofascial pain syndrome. When your
muscles are chronically sensitive to touch and painful with movement, you may have
inflamed areas of muscles or trigger points. Injecting the muscle with a local
anesthetic/steroid may reduce the inflammation and allow better range of motion.
Typically, stretching and exercise, especially with physical therapy, will assist with this
process. Also may require electrical stimulation with a TENS (Transcutaneous
Electrical Nerve Stimulation) unit.
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Peripheral nerve injections
The most common peripheral nerve blocks are of the intercostal nerves (between the
ribs), ilioinguinal and/or genitofemoral nerves for groin pain, the lateral femoral
cutaneous nerve for upper thigh pain, and greater and lesser occipital nerve injections
for headaches in the back of the head. However, chronic nerve irritation may occur
with any nerve post surgery. As examples, intercostal injections may be required for
post thoracotomy pain, and ilioinguinal and/or genitofemoral nerve injections may be
required for post hernia repairs or other lower abdominal incisions. Intercostal nerve
injections are also performed for treatment of post herpetic neuralgia. Lateral femoral
cutaneous nerve blocks are done for people with a condition called meralgia
paresthetica (pain on the front of your thigh). This is typically the result of a nerve
entrapment from wearing too tight of a belt or in obese people with the abdomen
hanging over the waist line, and sometimes can occur during pregnancy or delivery of
a baby. Entrapment of nerves can occur with almost any peripheral nerve for a variety
of reasons. Most of the peripheral nerves are amenable to a local anesthetic/steroid
injection.
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Radiofrequency ablation
Radiofrequency (RF) techniques require a special machine allowing interruption of the
nerve conduction on a semi-permanent basis. With the “classic” RF technology, RF
waves pass down a needle causing an increased temperature and partial destruction
of the nerve it is near. This is most commonly done for people with neck or back pain
who have had a very good response (but unfortunately only for a short period of time)
with a steroid injection of their facet joint. Newer technology allows us to do a “pulsed”
RF, or intermittent bursts of RF, creating an electromagnetic field (EMF) about the
nerve to interrupt the nerve conduction. Pulsed RF is most commonly done with
peripheral neuralgias on nerves that have only a sensory component (i.e., only on
nerves that do not also innervate or control our muscles). Prior to either RF technique,
diagnostic blocks with local anesthetic only are required. Unfortunately, often both RF
techniques may require a repeat procedure one to two years later.
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Cryoablation
Cryoablation is most commonly done on peripheral nerves with only a sensory
component (i.e., only on nerves that do not innervate or control our muscles). A probe
is placed near the nerve and a special machine actually produces an ice ball around
the nerve. This causes partial destruction of the inside of the nerve, but allows the
outer part of the nerve to remain intact. This is important as when any nerve is cut or
partially destroyed, the nerve will try to grow back. With the outer part of the nerve still
intact, this allows the nerve to follow the correct path, which is felt to prevent a post-
procedure “neuritis”, often seen with other neurolytic techniques. Unfortunately, if
successful, cryoablation may require repeat procedures in six to twelve months.
Diagnostic nerve blocks are required prior to doing cryoablation.
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BOTOX
BOTOX injections for pain are most commonly done for migraine headache sufferers
resistant to all other present treatments. BOTOX (Botulinum toxin) prevents the release
of a neurotransmitter, acetylcholine, which typically causes the contraction of a muscle.
Injection of small amounts of BOTOX into the cranial muscles relaxes these muscles.
This helps to prevent a viscous cycle between the peripheral nervous system and
central nervous system. The BOTOX injections may require repeat injections every six
to twelve months.
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Discograms
Discograms are done to help diagnose your pain and not to treat your pain. Although
dye is injected into your disc and x-ray pictures (and sometimes a CT scan) are taken,
the pictures are not as important as your response to the dye being injected (see below).
Discography is most commonly done at the lumbar level for people who have failed
extensive conservative treatments yet continue to have disabling low back, buttocks,
hip, groin, or thigh pain that may be caused by the disc itself hurting. Often, MRI/CT
scans may only show mild degeneration or mild bulging of the disc, and sometimes a
tear is seen in the disc. These changes do not necessarily result in a painful disc,
unless there is also inflammation. Presently, the only way to determine if the disc itself
hurts is by putting dye into the disc. You are sedated and comfortable while the needle
is placed into the disc. You are awake and talking while the dye is being injected. With
a normal disc, you may feel pressure but no significant pain. However, with a problem
disc, one feels considerable pain very comparable to their typical pain pattern.
Obviously, this is very helpful in determining the next step in your treatment.
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Vertebroplasty
Vertebroplasty is a new procedure sometimes done for patients with lower thoracic
and lumbar vertebral compression fractures. However, typically vertebral compression
fractures do heal over time and can be treated with pain medications, bracing, and/or
epidural steroid injections. If these more conservative measures fail, then one can
consider doing a vertebroplasty. This requires careful placement of one to two needles
into the vertebral body. Slow injection of a special glue containing dye while looking at
an x-ray machine is done. If any of the dye goes into a blood vessel or near the
epidural space, the procedure may have to be stopped before completed. The
procedure does have the risk of paraplegia and possible death, however, it often helps
decrease the pain and decrease the amount of pain medications required.
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Spinal Cord Stimulation (SCS)
SCS uses similar technology to a pacemaker with the end result being an electrode
placed in the epidural space which is connected to a pulsed generator placed under
your skin (typically upper abdomen or buttocks). This technology is usually reserved
for patients with refractory extremity pain not responsive to other conservative
treatments. Turning on the electrode causes a “tingling” sensation which helps to
decrease the perceived pain of the involved extremity. A trial lead is placed first and
connected to a generator outside of your body. The patient then goes home for two to
three days with the trial lead in to determine if this technology works for the patient. The
trial lead is then pulled. If the trial was successful, the total system is then implanted
two to four weeks later. Adjustments may be made with an external computer if
required.
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X-ray/fluoroscopy/C-arm
Some procedures will require use of an x-ray/fluoroscopy machine referred to as a
C-arm. Our C-arm is equipped with the most advanced, state-of-the-art technology
providing us, you, and your referring doctor with beautiful digital pictures. The pulsed
technology and collimator allows decreased exposure to you and our staff. The digital
subtraction technology not only give us better pictures but allows us play back,
decreasing your risks. The “super C-arm” allows us to do larger patients easily and
gives one more room, making one feel more comfortable during the procedure and
giving the doctor more space to better perform your procedure. To compliment our
C-arm, our comfortable imaging table allows movement in any direction getting you off
the table in a timely, efficient manner.
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IDD Therapy
IDD Therapy ® - Intervertebral Differential Dynamics Therapy® is the
innovation chronic, lower-back pain sufferers have been anticipating. IDD
Therapy ® was developed by an advanced team of back specialists. Including:
neurosurgeons, orthopedists, osteopaths, and physical therapists among other
medical professionals.
With an impressive success rate, thousands of patients have experienced dramatic
pain relief and healing utilizing IDD Therapy ®. IDD Therapy ® is level-specific
distracting the vertebrae thereby reducing pressure and promoting healing by
allowing better nutrition and hydration of your discs.
IDD Therapy ® has proven effective for the relief of lower back syndromes,
including:
- Herniated or bulging discs
- Degenerative disc disease
- Posterior facet syndrome
- Sciatica
- Acute or chronic back pain
IDD Therapy® is non-surgical, non-invasive, and typically does not involve
pain medications. The treatment is not only safe and painless, but also comfortable
and relaxing. The course of therapy includes private, out-patient treatment sessions.
Each treatment is conducted reclined upon an advanced, patent pending physio-therapeutic
bed.
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Joint Injections
Synvisc is used to treat osteoarthritis. When the synovial fluid becomes thinner and loses its elasticity and viscosity (ability to lubricate), the osteoarthritic synovial fluid cannot provide "cushioning" in your knee joint. A lubricant such as “Synvisc” is injected into the joint cavity to replace the lost synovial joint fluid.
Corticosteroid
Injections aree used to treat conditions such as bursitis, tendonitis, and arthritis.
Intra-Articular Steroid Injections
Provide prompt and effective reduction in local inflammation. Steroid injections are often given into the joint cavity. Common examples are the knee, AC (acromiel-clavicular), and SI (sacroiliac) Joints.
Injections into Bursa
Used to reduce pain and inflammation of the bursa (which is a closed fluid-filled sac that functions to provide a gliding surface to reduce friction between tissues of the body). This injection does not go into the joint cavity itself. Common examples are the trochanteric bursa (hip), ischial tuberosity bursa (buttocks), and the pes anserine bursa (knee).
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