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, hypogastric plexus, and ganglion impar blocks), neurolytic procedures (radiofrequency lesioning and chemical neurolysis), Botulinum Toxin injections, intradiscal treatments (IDET, Nucleoplasty/ Coblation), kyphoplasty/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. Dr. Binegar will use fluoroscopy (X-Ray) or US ( Ultrasound) imaging to ensure proper placement of your 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.
To enhance the body's own repair mechanisms is the ideal sought-after approach in all of medicine, as human physiology and function will always be better and more complete than any pharmacological or surgical fix. Regenerative medicine covers a broad range of therapies from organ transplants to wound healing to many pain therapies. The regenerative medicine techniques utilized at PCB include Stem Cells, Platelet-Rich Plasma (PRP) therapy and Prolotherapy. Athletes and even the elderly are now able to take advantage of this technology. These regenerative medicine techniques help repair or strengthen musculoskeletal problems such as osteoarthritis, tendon defects, meniscus tears, degenerative disc disease, and cartilage defects. To learn more, check out the following pages on Stem Cell Treatments, PRP and Prolotherapy.
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.
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.
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.
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. 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.
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.
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.
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.
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.
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.
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.
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 due to facet arthritis, 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. RF often provides permanent benefit, but does sometimes require a repeat RF in the future.
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.
Kyphoplasty and/or Vertebroplasty are new procedures 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 facet/epidural steroid injections. If these more conservative measures fail, then one can consider doing a kyphoplasty or vertebroplasty. This requires careful placement of one to two needles into the vertebral body. With a kyphoplasty a cavity is first created within the vertebral body. Slow injection of a special cement glue containing dye is done while looking at an x-ray machine. 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 extra increased risks of paraplegia, pulmonary embolus and possible death. However, it often helps decrease the significant pain and decrease the amount of pain medications required.
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.
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.
Orthovisc or Synvisc may be used to treat knee osteoarthritis to prevent or delay needing a total knee replacement surgery. 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 Orthovisc is injected into the joint cavity to replace the lost synovial joint fluid.
Corticosteroid injections are used to treat conditions such as bursitis, tendonitis, and arthritis.
Intra-Articular or JOINT
Provide prompt and effective reduction in local inflammation. Steroid injections are often given into the joint cavity. Common examples are the shoulder, hip, knee, AC
(acromial-clavicular), and SI
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 subacromial
bursa (shoulder), trochanteric
bursa (hip), ischial tuberosity
bursa (buttocks), and the pes anserine
Injections are commonly done for tendonitis or tendinopathy problems to decrease the pain and inflammation. Common examples are tennis elbow and golfer's elbow (epicondylitis), rotator cuff( shoulder), runner's knee ( iliotibial tract), jumper's knee (patellar tendon) and others.
All of the above injections are done with US (Ultrasound) guidance, allowing us to see the intended structure.
Recent advances in high-resolution Ultrasound (US) imaging present new opportunities in improving the care of patients with pain due to musculoskeletal and nerve injuries. US uses sound waves to provide real-time, high resolution images of tendons, ligaments, muscles, and nerves throughout the body. US allows us to deliver treatments precisely and safely to the effected tissue. During ultrasound-guided injections, Dr Binegar and his trained staff can directly visualize the needle passing to the targeted tissue. Direct visualization ensures accurate placement of the medication and offers a greater margin of safety. Smaller needles
can be used, improving patient comfort and potentially reducing risk to the patient.
Applications for ultra-sound-guided injections include:
- Needle placement into joints for injection
- Injection into tendon sheaths and bursa
- Aspiration and injection of ganglion cysts
- Diagnostic or therapeutic nerve blocks, including carpal tunnel syndrome
Traditionally many doctors still do the above mentioned joint/nerve blocks with what is referred to as a blind
or landmark technique. With US
we are able to see the structure and therefore the possibilities of helping relieve your pain are greatly enhanced.