Pain Management

Epidural Steroid Injections are a common method of treating inflammation in the leg or arm relating to narrowing of the passages where nerves travel as they pass down or out of the spine. The passages may become narrowed by several different causes, such as disc herniations, bone spurs, abnormal alignment of the vertebra, thickening of the ligaments, or joint cysts. This causes the nerve to become swollen, causing pain, numbness, tingling or weakness in the arms or legs.

The patient is injected the medication through the epidural space, the area between the protective covering of the spinal cord and vertebrae, with the use of fluoroscopy (X-Ray) to guide the needle into the space. After receiving the injection, the patient should feel some relief within 1-3 days (can vary), and in some cases, improvement in the pain and functionality can last for several months. The injections typically relieve pain, however, over time the injection strength will subside, and a series of blocks may be needed to relieve pain. For relief of pain, injections have a 75%-85% success rate in the short term. Long term is variable and appears to depend on compliance with treatment plans and back-sparing activities of daily living.

To make a diagnosis, some clues are present in the history or physical exam, but are not enough to claim. Similarly, X-Rays and MRIs can show arthritic joints, but not all arthritic joints are painful, and not all painful joints are arthritic. To be certain if a joint is responsible for pain, a diagnostic block is performed.

The facet joint block, or zygapophysial joint block, is used to determine whether a facet joint (joints that guide and restrict the spines movement and where a vertebra slightly overlaps another) is a source of pain. If the joint feels relief, then the problem area has been isolated. In order to prevent “false positives”, the diagnostic blocks are always performed twice.

Sacroiliac joint blocks are used to treat or diagnose low back pain or symptoms related to sacroiliac joint dysfunction, such as sciatica.

The use of the SI injection for a diagnosis is done by injecting the SI joint with medication under fluoroscopy (x-ray) guidance, and then asking the patient to perform normal activities (that would have once brought on pain). If the pain has subsided by a significant amount, then a tentative diagnosis is made. Pain relief treatments consist of the same procedure, but may include anti-inflammatory (“cortisone”) medication to reduce swelling within the joint. The steroids may take one day, or up to two weeks to reach peak effectiveness. Repeat injections may needed to be performed.

Once pain has subsided for the patient, he or she can begin a physical therapy or rehabilitation program to further reduce pain and return to normal activities. If the injection is effective, but does not last long, radiofrequency neurotomy (RFA) will be considered to provide longer lasting relief.

SCS works by delivering small electrical pulses to the pain sensing pathways of the spinal cord, effectively altering the pain signals traveling to the brain.

SCS is typically prescribed for the treatment of pain of the back, trunk, or limbs. It is most commonly used to treat severe low back and lower extremity pain. Thousands of patients with severe chronic painful conditions have received relief with spinal cord stimulation.

Overview of Spinal Cord Stimulator Systems

The key components of a rechargeable SCS system are leads, an implantable pulse generator (IPG), patient remote control, and a portable charging system.

• The leads are thin wires that deliver precise pulses from the pulse generator to the spinal cord.
• The implantable pulse generator (IPG) is an implantable device that features a rechargeable battery and other electronics that deliver the pulses to the leads. The pulse generator is placed surgically under the skin, usually in the buttock or the abdomen. The IPG is similar in function and appearance to a pacemaker.
• The remote control device allows the patient to turn the system on and off and adjust stimulation within parameters set by physicians.
• The charging system is used by the patient to recharge the IPG battery after it is implanted.

Determining if SCS Therapy is Appropriate for a Candidate

SCS therapy offers an evaluation period: a candidate for SCS can test-drive the therapy during the evaluation period using a temporary external system. To trial the therapy, a minor procedure will be performed to place the leads in the candidate’s back. Leads are positioned using a small needle. They are then connected to an external pulse generator that is worn on a belt for 5-7 days. During this period, the system’s programs are adjusted and fine-tuned to best alleviate the patient’s pain. After this period the candidate will report to the doctor how much pain relief was felt. Together, the candidate and doctor can decide if SCS therapy is something they would like to continue to receive. If so, receiving an SCS implant is the next step. This requires a minor surgical procedure to place an implantable pulse generator (IPG) beneath the skin.

The High-Frequency Breakthrough

Traditional spinal cord stimulation (SCS) delivers mild electrical pulses which attempt to mask pain with a tingling or buzzing sensation called paresthesia. Nevro revised and updated this approach with a proprietary, high-frequency waveform that allows a method of relieving pain without paresthesia. Data also suggest high-frequency SCS is able to provide pain relief in some patients for whom low-frequency SCS is ineffective.

Clinically-Backed Therapy

Clinical evaluations and patient experiences in leading centers worldwide have shown promising pain reductions even in difficult-to-treat chronic pain conditions, including severe low back pain. In addition to pain reduction, clinical evaluations reveal that many patients can reduce their intake of pain medications and may experience an improved quality of life.

Paresthesia-Free Pain Relief

10 kHz high-frequency spinal cord stimulation therapy (HF10 therapy) is the first paresthesia-free SCS therapy. In addition to the freedom from persistent tingling or buzzing, HF10 therapy does not cause jolts and shocks related to over-stimulation that traditional SCS patients may experience during positional changes (for example, standing up, sitting down, bending over). This key difference allows the Senza® system to limit sleep disturbances. In addition, unlike traditional SCS, operating motor vehicles while using the Senza system is not restricted.

More Predictable Procedure

Since traditional SCS relies on paresthesia masking for effect, patients must be awakened during the implantation procedure to help physicians position the tingling sensation to overlap the area affected by chronic pain. Because HF10 therapy does not require paresthesia to be effective, physicians need not awaken patients during the implantation procedure.