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Pain Management

Dr. Dery & Dr. Goldish

SO… YOU ARE HAVING A STEROID INJECTION

In many cases of both chronic and acute back pain, spinal injections are used as both a diagnostic and therapeutic treatment of your pain symptoms. If your symptoms are due to a disc herniation, the steroid injection is not intended to remove the disc herniation. The steroid injection is intended to remove the inflammation surrounding the disc and any “pinched” nerves, during which time the herniation or symptoms should resolve and heal on its own (usually 6-10 weeks). Steroids are a strong anti-inflammatory medication used to reduce inflammation in the affected area. Sometimes this process may require up to 3 steroid injections (usually 1-4 weeks apart) in order to provide maximal pain relief. The number and type of injection will be determined by your doctor on an individual basis depending on your symptoms and response to prior injections.

Performing a steroid injection can do the following:

1. Provide pain relief.

2. Help determine your specific source of pain (diagnosis).

3. Provide immediate pain relief (usually in 2-3 days) to get you over the “inflammatory hump” and allow you to participate in physical therapy, home exercise, and daily physical routines.

MEDICATIONS

A local anesthetic will be used to numb the site of the injection. The steroid can cause a numbing effect which can last up to 8 hours and may cause short-term weakness or low blood pressure.

Steroids may not begin working until up to 5-10 days after administration, however, can provide long-term relief due to its powerful anti-inflammatory properties.

TYPES OF INJECTIONS

Epidural Steroid Injection (ESI)

An ESI is a type of steroid injection performed to treat an irritated or “pinched” nerve root or other pain generator, due to either a disc herniation or stenosis (tightening) of the spinal canal. The steroid is placed in the space between the covering of the spinal nerve and spinal cord (dura mater) and the bony spinal canal it lies in called the epidural space. The ESI can be done through different approaches such as a Caudal ESI (through the sacrum, in the lowest part of the lumbar spine), an Interlaminar ESI (through the midline of the back with some medication allowed to move up and down the epidural space) and finally the most specific approach- the

Transforaminal ESI

This approach is through the foramina (small openings between vertebrae through which the spinal nerve exits) to block specific nerves from the spine and is what Dr. Dery and Dr. Goldish typically do at Steindler.

ESIs are usually performed to treat “Radicular” pain or “Nerve” pain due to a pinched nerve in the back/neck, which often causes numbness, tingling, and pain in the leg or arm. They can also be used to treat other causes of pain, such as spinal stenosis or disc degeneration.

Facet/Medial Branch Injection

This type of injection is performed to diagnose and treat pain from specific joints of the spine called facet joints. Often the synovium becomes inflamed when the facet joints come too close together with degenerative arthritis, small inter-vetebral disc heights, and repetitive bending, twisting, and extension activities on a daily basis. By numbing the nerves to these joints, we can determine which joints are causing your pain and address them with a therapy that can give you long-term pain relief.

Facet blocks are usually performed to treat “Axial” pain, or “Mechanical” pain due to arthritic or inflamed joints of the spine which often cause sharp stabbing pains localized to the middle of the low back (or neck) worse with bending or twisting.

Sacroiliac Injection (SI)

This type of steroid injection is performed to diagnose and treat pain between the sacrum and the ilium which together form the pelvis. The SI joint is usually very limited in motion, however, changes in walking patterns, posture, obesity, and arthritis of the pelvis can cause the SI joint to be more pressured and inflamed. The steroid can help remove this inflammation to allow you to work with physical therapy or home exercise to strengthen the gluteal muscles, hamstrings, mobilize the SI joint, and improve your posture.

Hip Joint Injection

This type of steroid injection is performed to diagnose and treat hip pain between the femoral head (ball) and the acetabulum (socket) in order to alleviate pain and improve ambulation and function.

Shoulder Arthrogram

This type of injection is performed as a diagnostic phase 1 of an MRI study of the shoulder. Contrast dye is placed in the shoulder (glenohumeral) joint in order to more precisely localize tears and injury under MRI. This will be coordinated with our MRI personnel for safety, convenience and efficiency.

Commonly Asked Questions about Injections

PLEASE READ

1. What should I expect?

You will be asked to sign a consent for this procedure (unless already done in the clinic).

You will be placed in the prone position (on your stomach) on the X-Ray table; for hip and shoulder injections you will be placed in the supine position (on your back) and the area of interest will be sterilely prepared with betadine or chlorhexidine solution and a sterile drape. Several images will be taken in order to localize the site of needle entry. The needle entry site will be anesthetized with lidocaine, then the needle will be moved into position under X-Ray guidance. Contrast dye will be used to confirm proper positioning of the needle, and then the steroid-containing mixture will be injected. Your vital signs will be recorded before the procedure and, when the procedure is completed, you will then be escorted back to your recovery room for further monitoring before being discharged to home in the care of a responsible adult.

You will typically need an adult driver to leave with you for most procedures performed by Dr. Dery and Dr. Goldish.

2. Will the injection hurt?

This is a relatively variable answer, as different people tolerate pain and injections differently. I always use a local anesthetic to numb up the injection site prior to the needle entry and I always talk you through the procedure as it goes along. The whole procedure usually takes about 5-10 minutes. You will then remain in recovery for up to 15 minutes just to make sure things are well before you leave.

In my experience, most patients have left reporting “It really wasn’t bad at all.”

3. Why do I need a driver?

This is simply a safety precaution. Often patients may feel warmth, or numbing sensation in their legs after the injection for up to 8 hours due to the local anesthetic used, you may also feel dizzy or otherwise “not normal” which may impede driving.

4. When can I resume normal activities after the injection?

After the injection you should not operate a motor vehicle or heavy machinery for the remainder of the day of the procedure. You can ambulate as tolerated on the day of the procedure (you may be quite sore or somewhat unsteady), and you can resume all normal activity by the next day.

5. How will I know if the injection worked?

On the day of the procedure you can expect to have about 2-4 hours of numbness in the back and lower legs (or arms) due to the local anesthetic effect. Even the feeling of “numbness, warm feeling, and difficulty moving my legs” is normal for the first 8 hours after an epidural steroid injection. Once this wears off, you will have quite a bit of soreness at the injection site for about 24 hours. Make sure to ice the injection site for 20 minutes every hour, for 3-4 hours on the day of the procedure; this will significantly decrease the soreness. You may need to take over the counter Tylenol to help with post-procedure soreness. You may also need to take over the counter Benadryl (tablet or lotion) to help with minor itchiness at the injection site. Dizziness is common right after the injection. If dizziness has occurred days following the injection please see your primary doctor.

The steroid medication will begin working in 48-72 hours in most people, and its effects may last up to 3-6 months or longer. Please wait 10 days for the steroid to take full effect. If you do not have any relief after 10 days, please call our office to see what the next step is.

You should monitor and record the extent and duration of relief (a pain diary) you have received for the next 1-2 months. You can call us to set up repeat procedures if your typical pain returns without new symptoms.

6. What should I expect immediately after the injection?

Common short-term side effects of the steroid include nausea, dizziness, fatigue, irritability, difficulty sleeping, high blood sugar, and fluid retention. If diabetic, you will need to monitor your blood sugars more closely for 72 hours. If you have kidney disease or heart disease you will need to contact your primary care doctor prior to the procedure to monitor your fluid retention more closely after the procedure.

Warmth and numbness in the legs (or arms), and paresthesia in the legs (lack of feeling or movement in the leg) may last up to 8 hours after the injection due to the medications.

You may have significant tenderness and pain at the needle entry site after the numbing medication wears off in 3-4 hours. Make sure to ice the area for 20 minutes every hour which should take care of any swelling.

You may have minor itching and redness around the needle entry site. Please wash this area off thoroughly and take an over the counter anti-histamine (Benadryl ointment or tablet) to help with the itching. Remove the Band-Aid(s) after 8 hours to prevent further skin irritation.

7. How often can these injections be done?

On average we do no more than 3 injections within 6 months. Factors considered include age, amount of steroid used, site of injection, and diagnosis. There is research to support doing a second ESI if you have no relief from the first injection. There is no evidence to support doing more than 2 injections if you have no relief from either of the injections. The number of injections done will be determined on an individual basis.

8. Why do I have to stop my anti-clotting agents before the injection?

Medications such as Coumadin, Plavix, Aggrenox, Lovenox, high dose Aspirin, and Aspirin like products/blood thinners prevent clotting of blood at the procedure site as well as within the spine itself which could lead to unnecessary complications. Please check with your primary doctor before stopping these or similar medications. Keep in mind your injection procedure is elective and may take second priority to your other medical issues. If your doctor does allow you to be off Coumadin you will need an INR of 1.5 or less on the day of the procedure. For other blood thinners please speak with a medical assistant. We can phone orders to your local blood draw lab if needed, so please let us know.

We ask that you do not take NSAIDS (Ibuprofen, Aleve, Diclofenac, etc.) for 24 hours prior to the procedure, but you can take them starting the day after your procedure. Please be advised that many OTC medications contain aspirin (e.g. Excedrin) and we require you to be off these for 7 days before any procedure. It is YOUR responsibility to know what you are taking and what is in each medication you take!

9. What medications can I continue to take?

You do not need to stop any other medications outside of anti-clotting agents mentioned above for the procedure, oral hypoglycemic or Metformin. You may continue muscle relaxants, anti-depressants, blood pressure medications, insulin, Tylenol, Vicodin, Nucynta, Tramadol or other opioids.

10. When can I begin my medications after the injection?

You can begin all medications except for blood thinners and NSAIDs right after the injection. This includes any pain medications such as opioids. You can begin taking your blood thinners (Coumadin, Plavix, or Aspirin like products) the day after the injection.

11. When should I call the clinic or the Emergency room after the injection?

If you have any symptoms of bowel/bladder incontinence (e.g. cannot feel or control when you are having bowel movements or urination), high fever, chills, severe pain, progressive weakness, or headache within 48 hours of the injection, please call us at the clinic (during normal business hours of 8:00 am to 4:30 pm) so we may assist you. After our normal business hours, call 319-339-0300 and ask to have a physician on call paged, go to an ER or call 911.

12. What are the contra-indications to this procedure?

Please cancel the procedure if you are PREGNANT or MAY BE PREGNANT, or have an active INFECTION and you are on antibiotics. You must be off anti-biotics for 7 days without recurrence of the infection before we can do any procedures. We can wait or discuss alternatives to the injection if needed.

Please let your doctor know if you are diabetic (your BLOOD SUGAR WILL BE HIGH FOR 72 HRS), and/or if you have heart or kidney disease (you will have FLUID RETENTION).

Please let us know if you have medication allergies, iodine contrast dye allergies, or latex allergies so we may take the necessary precautions for your safety. If you have any questions please call us. Do not wait to come in for your procedure to have your questions addressed.

Thank you,

Fred Dery, M.D.

Daniel Goldish, M.D.

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