Spinal Injection Therapy

This month’s post will be discussing the mechanics and hopefully provide a better understanding about various types of spinal injections. These are common procedures performed by pain specialists and physiatrists in order to deliver medication more effectively to the location that is generating your pain. The solution injected is typically a steroid, anesthetic, or a mix of both. Conservative analysis suggest that greater than 50% of patients will experience pain relief with these injections, although exact relief will depend on each individual’s factors and situation. This blog will focus primarily on X-ray guided injections.

The function is two-fold. First being diagnostic; allowing us to deliver an anesthetic medication to a suspected source of pain to either confirm or rule out suspected pain sources and help guide further treatment. If pain relief is achieved, we can infer that the region injection is indeed your problem. Once we know where the pain is coming from then we can discuss definitive treatment options if the pain returns.

Second, and most importantly, spinal injections often providepain relief for the individual.  Sometimes the injection provides enough pain relief for a long enough duration that the body can heal itself and no additional treatment is needed.

Here is a list of the most frequent types of spine injections utilized.

-Epidural injection

-Selective nerve root block

-Facet joint or medial branch block

-Costovertebral joint injection

-Sacroiliac joint injection

-Radiofrequency ablation

Epidural steroid injections can be performed in any region within the spine, from the neck to the lower back and sacroiliac joint. Prior the procedure, the treatment site will be cleaned and then numbed with local anesthetic. There are different routes these injections may be placed; namely transforaminal and interlaminar. The most common approach, transforaminal, is when the needle tip is inserted into the opening in which each nerve root exits the spine, called the foramen. This injection is done under x-ray guidance which allows the medication to be specifically delivered to the right location. This allows the anti-inflammatory medicine or steroid to be injected near the source of potential inflammation of the nerve root and alleviate back or leg pain. The interlaminar approach is used by inserting the needle along the back of the spine, into the space between the vertebrae laminae and resulting in more generalized pain relief. It is commonly employed in situations involving degenerative lumbar spinal canal narrowing. A common injection is called a caudal epidural, in which many areas of the lumbar spine are injected through one needle stick at the very bottom of the lumbar spine.  The goal of this injection is primarily pain relief.

Selective nerve root blocks are used similarly to epidural injections; both to diagnose and treat inflamed spinal nerve roots, although provide an alternative approach in needle positioning. While a transforaminal injection is placed within the nerve root opening, a selective nerve root block is positioned adjacent or next to the nerve root. This allows for the use of less steroid and improved safety considerations, although may experience shorter-term relief compared to other injections.

Facet or medical branch blocks are utilized to diagnose and treat more localized back or neck pain that originates from the joints in your spine called your facet joints. Facet joint pain is a very common cause of chronic lower back pain. There are capsules surrounding these joints that are innervated by small nerves that become inflamed due to injury or arthritic degeneration. These injections can be placed into the joints themselves or to the medial branch nerves that feed into and supply the facet joints. The overall goal is to suppress the nerves within the joints from signaling pain to the brain. Pain relief is usually temporary, typically 1-4 weeks or potentially longer. The symptoms may or may not return depending on your circumstances. If these injections gave great relief but the pain returns than patients are often set up for a follow-up procedure called a radiofrequency neurotomy or ablation.

Radiofrequency ablations are different from the above mentioned procedures as a RFA involves heating / deadening a part of a pain-transmitting nerve to create a blockage of pain from the facet joints. Once the lesion is created, the previously painful nerve pathway cannot send pain signals to the brain. This is most commonly used in treatment of low back pain generated in the facet joints. Typically, diagnostic nerve or facet blocks are performed initially to identify areas that should be treated with RFA. The effects from the ablations may last for several months to a year or even longer, but the nerves will often regenerate with time with a potential return of the pain.

Costovertebral injections involve your thoracic or mid-back in which your ribs connect to your spinal column. Rib dysfunction syndromes can occur causing localized rib pain or upper back pain. In these cases, you can undergo these injections for further diagnosis or treatment. The injection delivers the medication or steroid into the smaller joints where the ribs join the spine. Often the goal of this procedure is to decrease inflammation and pain, allowing the individual to better tolerate a physical therapy or rehabilitation program.

Sacroiliac injection involves the region in which your pelvis meets your sacrum, called the sacroiliac joint. Pain may originate from the joint itself or the ligamentous tissue surrounding it. People often feel pain on one side of the upper buttock or the other.  Sacroiliac pain can be caused by trauma but can also be degenerative in nature.  This can follow longer low back fusions, but can arise on its own as well. While the initial pain relief can be substantial, unfortunately not all injections are effective in the long-term. They are primarily utilized to diagnose and improve functional capacity to increase participation in rehabilitation treatments.

Safety precautions and potential risks

In general, these injections are a low risk, useful, non-surgical tool to combat neck, back and limb pain caused by inflammation. However, while extremely rare, potential risks include infection, dural punctures, bleeding, and nerve damage.

All of these injections will be performed either under the use of fluoroscopy (x-ray) or ultrasound in order to confirm appropriate needle placement. A contrast dye is also often utilized with the imaging in order to prevent the injection of medication into blood vessels or other unwanted tissue.

Light sedation may also be used that may make you feel numb or slightly weak/odd feeling for a few hours after the injection. This may last several hours, but the patient should be able to function safely, if proper precautions are taken. Most often, the individual will require a driver home but may return to work the following day. On the day of the injection, patients should avoid doing any strenuous activities. If any sedation was used, the patient should not drive for 24 hours after the procedure.

Patients may notice a slight increase in pain lasting for several days due to the needle irritation or by the steroid itself. The steroids typically take effect 2-3 days following the injection but can take as long as a week.

Factors that may prohibit injections include skin infections, bleeding disorders, uncontrolled high blood pressure or diabetes, and allergies to anesthetics/steroids.

We at Summit Spine often utilize injections to help relieve the patient's pain and also confirm the source of the pain.  Although we do not perform these injections ourselves, we are glad to see you and arrange the appropriate referral through many well vetted providers in Oregon and Washington.  Call us today if you feel one of these injections may benefit you!

Author

Kolten Paryzek PA-C