Non-surgical treatments for spine conditions
Epidural Steroid Injections
Epidural spinal injection is a non-surgical treatment option utilized for relieving back pain. Spine degenerative conditions such as herniated disc, spinal stenosis and many others may induce back pain due to the compression of the associated spinal nerves. This pain or numbness may extend to the other parts of the body such as hips, buttocks, and legs. Doctors start with non-surgical methods to treat back pain and epidural spinal injection is one of these preferences. In cases where the patient finds no relief from non-surgical methods then finally surgery is recommended.
Epidural spinal injections contain a strong anti-inflammatory agent called corticosteroid and an anesthetic for pain relief. It is not the same as epidural anesthesia given before child birth to decrease labor pain. Epidural injections are administered into the epidural space of the spine. The epidural space is the space between the outermost covering of the spinal cord (dura mater) and the wall of the spinal canal. It is approximately 5mm wide and is filled with spinal nerve roots, fat and small blood vessels.
An epidural spinal injection may be employed both for diagnostic and therapeutic reasons, including:
- Medications to determine the specific nerve root involved in the spinal problem (diagnostic purpose)
- Medication for inducing short or long-term relief from pain and inflammation (therapeutic purpose)
It is to be noted that epidural spinal injection is not a curative intervention, rather it’s a treatment tool to reduce the discomfort of the patient so that rehabilitation programs such as physical therapy may be well executed.
Pain management in different conditions such as spinal stenosis, disc herniation and arthritis can be done through epidural injection. Different types of physicians such as physiatrists, anesthesiologists, radiologists, neurologists, and surgeons may recommend epidural injections for pain relief.
Usually epidural spinal injection is done on an outpatient basis. The procedure involves the following steps:
- Patient is taken to the pre-op area where trained nursing staff makes prepares the patient for the procedure by taking vitals and reviewing medications. Blood sugar and coagulation status may also be checked if needed.
- Patient is taken to the procedure room and will lie face down on a table.
- The injection site is then cleansed, and injection of a local numbing agent is given in the area so that you don’t feel pain during the procedure.
- A thin hollow needle is then inserted into the epidural space, guided by fluoroscopic X-ray to place the needle in the correct position. This system gives real time X-ray images of the position of the needle in the spine on a monitor for the surgeon to view.
- A contrast material is then injected through the properly placed hollow needle to confirm that the drug flows to the affected nerve when injected.
- When the doctor is satisfied with the position of the needle, the anesthetic drug and corticosteroid are injected through the same needle inserted in the spine.
- Finally, the needle is removed, and the injection site is covered with a dry, sterile bandage.
Patients may feel some pressure during the injection but mostly the procedure is painless. The procedure takes about 15-30 minutes to complete. After injection, the patient should not drive or go back to work and should rest and avoid any vigorous activities. Your surgeon may give specific post-care instructions. Please follow the instructions to recover faster.
Patients may feel numbness in the arms or legs just after procedure along with other side effects related to the anesthetic component that usually settles down within 1-8 hours. Patients may continue to feel some back pain, as epidural spinal injections take about 24-72 hours before showing their pain-relieving action. In some cases, if the desired effect is not obtained, then reinjection may be recommended. The standard guidelines for steroid injections state a maximum of 3 injections per year. In case no relief is obtained from spinal injection, then surgery is considered as the final option.
Risks and complications
With any procedure some risk factors will always be there. Likewise, epidural spinal injections have complications such as bleeding or infection at the injection site, pain during or after injection, post-injection headache, nerve injury, bladder dysfunction, fluid retention, respiratory arrest, epidural hematoma, and spinal cord infarction. Discuss with your doctor if you have any concerns prior to the procedure.
The facet joints are the tiny joints situated at the upper and lower part of each vertebra connecting one vertebra to the other. Each of the vertebrae has four facet joints which include a pair that connect to the vertebra above (superior facets) and another pair that connects to the vertebra below (inferior facets). They guide motion and also provide stability. Pain may arise in these joints as a result of an injury to the back, spinal arthritis, or because of increased stress on the backbone. A minimally invasive treatment called facet injection offers symptomatic relief of the back pain caused by inflammation of the facet joints but is not a permanent solution for the condition.
The facet injection procedure may be performed primarily as a diagnostic test to check whether the pain is actually originating from the facet joints. Secondly, it is used to treat inflammation caused by several spine conditions. A facet injection contains a long-acting corticosteroid and an anesthetic agent which is given either directly into the painful facet joint capsule or into the tissues near the joint capsule. The objective of the treatment is to suppress the pain so that normal activities can be resumed, and patients can perform physical therapy exercises.
Facet injection is indicated in conditions where all other conservative treatment modalities such anti-inflammatory medications, rest, back braces and physical therapy have become unsuccessful. Facet injection may reduce inflammation in the facet joints caused by conditions such as spinal stenosis, spondylolysis, sciatica, herniated disc, and arthritis. This treatment is not appropriate for patients with an infection, bleeding disorder or during pregnancy. Patients on aspirin or blood thinners will be advised to stop taking them several days prior to the procedure.
Facet injection is performed as an outpatient procedure where you can return home on the same day but make sure you have someone along to drive you home. Usually the procedure lasts for around 15-30 minutes followed by a short recovery period.
You will be lying face down on a table and be conscious throughout the procedure. Sedatives may be given to make you comfortable and a local anesthetic is administered to numb the area of injection. Then, your doctor will insert a hollow needle through the skin and muscles into the sensory nerves situated at the facet joints under the guidance of a fluoroscope. Once the position of the needle is confirmed, the medication is injected into your facet joint capsule following which the needle is withdrawn.
Risks and Complications
Facet injections are considered as the most appropriate nonsurgical means of treatment with minimal risks. The possible risks and complications associated with needle insertion may include bleeding, infection, allergic reaction or damage to the nerves. Some of the adverse effects of the corticosteroid medication include weight gain, water retention, flushing and mood swings which usually resolve in 3 days.
Radiofrequency ablation (RFA) also called rhizotomy or neurotomy is a novel non-surgical technique of treating pain. This technique employs radiofrequency waves to produce heat and the heat produced damage the nerves transmitting pain signal to the brain. This procedure is performed to treat painful facet joints in the spine that usually cause chronic low back pain and neck pain.
Radiofrequency ablation treatment is considered only after it is confirmed that the cause of back pain lies in the facet joints and this is confirmed by performing a diagnostic facet joint injection. Facet joint injection relieves pain for a short duration whereas radiofrequency ablation can keep you pain-free for a longer period of time.
Radiofrequency ablation is a minimally invasive technique and therefore administration of general anesthetic is not required. You will be conscious throughout the procedure and lying on your stomach. Only a small area over your back which requires treatment is cleansed and numbed. This procedure is performed under the guidance of fluoroscopy. The fluoroscope is a special kind of X-ray machine that helps doctors to visualize the placement of the needle electrode in invasive procedures.
During the procedure, your doctor will direct a special radiofrequency needle electrode close to the facet joint in such a manner that the needle tip lies almost near to the medial branch nerve. The needle tip is then heated so that the nerve gets cauterized and destroyed thereby reducing the pain. This procedure may last for about an hour or two.
Sacroiliac Joint Injections
Sacroiliac joints (SI joint) are joints in the lower back region, located where the sacrum and ilium bones conjoin. Despite the fact that these joints are small and have limited motion, they have an important role of connecting your spine to the pelvic bone and thus the lower part of your body. They perform important functions by absorbing the injurious shock forces of the upper portion of the body. Any inflammation or irritation in SI joints may cause pain in the lower back, abdomen, groin, buttocks or legs.
Sacroiliac joint injections can be used both for diagnostic as well as therapeutic purposes. As a diagnostic tool, it helps your doctor locate the origin of pain. To diagnose SI joint pain, an anesthetic injection is given to the joint under X-ray guidance. An acute relief in low back pain following the injection indicates an abnormality in SI joint. For therapeutic uses, SI joint injections will contain a steroid medication along with an anesthetic agent in order to provide relief from pain for a longer duration. When steroid medication is injected into the painful & inflamed joint, the inflammation reduces and thus relieves the pain.
You will have an intravenous catheter placed in your arm before the procedure begins. The catheter is to provide medications if necessary during the procedure. You will be lying on your stomach and the area where the needle is to be inserted near the SI joint is numbed with a local anesthetic injection. Then your doctor will advance the needle under the fluoroscopic guidance. Once the needle is in the right position the medication is injected.
Risks and Complications
Complications are very rare, but do occur sometimes. Possible complications after SI joint injections include allergic reaction, infection, and increased pain.
Medial Branch Block Injections
Medical branch block is an injection of a local anesthetic near the medial branch nerves to temporarily block the pain signal carried from the facet joints of the spine to the brain. It is used to assist your physician in diagnosing the cause of your back pain.
Facet joints are the joints connecting the different vertebrae of the spine to each other. Medial branch nerves are small nerves that supply the facet joints of the spine. If a medial branch block is successful in confirming the patient’s back pain is originating from the facet joints, Radiofrequency Rhizotomy is indicated to provide longer pain relief.
Indications and contraindications
Medial branch block injections are usually indicated in patients with back pain originating from arthritic changes in the facet joints or from mechanical stress to the back. A medial branch block can be performed for the diagnosis or treatment of pain arising from the facet joints.
The procedure cannot be performed on patients taking blood-thinning medications or who have an active infection. Also inform your doctor if you are allergic to medications used for the procedure. Be sure to discuss these situations with your physician before the procedure.
A medial branch block procedure is performed under fluoroscopy (X-ray) guidance for accurate placement of the needles and to avoid nerve injuries. The basic steps involved in the injection procedure include:
- The patient lays on their stomach on an x-ray table. The area of the skin to be injected is cleansed properly and a local anesthetic is administered to numb the skin. A stinging or burning sensation may be felt for a few seconds.
- A small needle is then directed into the medial branch nerve area, under X-ray (fluoroscopy) guidance.
- Contrast dye is used to confirm the location of the needle over the medial branch nerves.
- Following this, a small mixture of the numbing agent and steroid medication, is then slowly injected over the targeted nerves.
The whole procedure takes about 20-30 minutes and patients can go home on the same day.
After the medial branch block your pain may either
- go away for a few hours
- go away for a few days or
- not reduce at all
If the pain is relieved after the medial branch block, this indicates that the origin of the pain is the medial branch nerves supplying the facet joints.
Based on the amount of pain relief observed during the first 6-12 hours after the injection, the patient may be considered suitable for a Radiofrequency Neurotomy procedure to relieve the pain for a longer period of time. In Radiofrequency Neurotomy, an electrical current is passed through a needle to the selected medial branch nerves causing pain in order to interrupt the pain signals.
Patients are advised to avoid driving and doing any vigorous activities on the day of the injection. You should arrange for someone to drive you home after the procedure.
The patient may experience localized pain at the injection site in the first 2-3 days for which ice packs can be applied to ease the discomfort. Patients may continue their routine prescribed medications after a gap of 4-6 hours following the procedure, in order to avoid incorrect assessment of diagnostic results related with pain relief.
Patients can return to their regular activities, a day after the procedure. In cases where improvement in the pain is seen, patients are advised to perform moderate activities, with regular exercises.
Risks and complications
Although medial branch block injection is a safe procedure, the possible risks and complications associated with the procedure include:
- Allergic reaction, usually with x-ray contrast dye
- Bleeding from the site of injection
- Infection at the site of injection
- Discomfort at the site of injection
- Increased pain
- Nerve or spinal cord damage and rarely, paralysis
Lumbar Spinal Bracing
Lumbar braces are external devices used to restrict movement of the lumbar spine and provide support and stability to the lower back region to relieve back pain and promote healing, after surgery or injury. Braces are also called orthotics and are made from different materials such as nylon, rubber, molded plastic and elastic cotton. The basic function of braces is to:
- Immobilize the spine, which helps healing
- Stabilize the injured area
- Manage pain by limiting the movement
Basically, braces are of two types, soft and hard braces. Soft braces provide support to the muscles and allows free movement while the hard braces limit the movement.
Soft lumbar corset
A soft lumbar corset provides supports to the affected muscles of the lower back. A lumbar corset is recommended to the patient suffering from conditions such as major arthritis, mild lumbar instability and low back pain. The lumbar corset prevents excessive movement of the lower back and promotes proper body posture. Long-term use of the soft lumbar corset can lead to weakening of the lumbar muscles. Therefore, the braces should only be used for a specified time period, as recommended by the doctor, along with regular muscle strengthening exercises.
Rigid lumbar braces
A rigid brace is recommended for providing additional immobilization, to minimize the risk of further injury, in conditions such as spinal fractures, unstable spine surgery and other related disorders. The rigid brace provides external stability to the affected spinal area for better healing.
The brace specialist is called an orthotist who is trained in different fields such as anatomy, biomechanics, material engineering, physical science and other related fields. In some cases, braces are fitted in consultation with an orthotist, as per the requirements of the treatment and condition of the patient. Your doctor may recommend the specific time-period for wearing the braces, which may range from weeks to months, depending on the condition and the type of disorder. Physical therapy may also be recommended along with braces.
Patients wearing lumbar braces should avoid activities that put undue strain on the affected area such as driving, lifting, etc. Follow the instruction of your doctor for taking baths and performing other activities. If the patient is recommended to take a shower with the brace, then at the end of the shower the braces should be cleaned properly.
Lumbar Spinal Injections
Lumbar spine injections are utilized in the assessment and treatment of low back pain. These injection procedures are valuable in determining whether particular structures are the source for low back pain. Pain initiated by lumbar facet joints is characteristically experienced in the lower back, hip, buttock, and/or leg.
Facet joints are tiny joints at each section of the spine that impart stability and facilitate and guide motion. The facet joints can become painful due to arthritis of the spine, a back injury or mechanical strain to the back. The pain relief obtained from a facet joint injection can help the patient tolerate a physical therapy schedule to restore his or her injury or back condition.
Facet joint injections generally have two objectives - to assist with diagnosis and also to impart pain relief. For more details about the specific procedures involved, please see PDF files below.
Cervical/lumbar traction is a therapy that stretches the spine to relieve pressure on compressed nerves and stretch tight muscles, in order to treat back and neck pain. It may also be used for realigning the spine in cases of dislocation. Traction may be performed manually or mechanically (with the use of weights and pulleys).
Excessive pressure on the spine from injury or stress may cause discs present between the vertebrae to herniate. Nerves exiting and entering the spine may become compressed by these herniated discs. Traction or spinal decompression therapy separates the vertebrae, reducing pressure, which may reverse disc herniation, facilitate uptake of healing nutrients into the disc, stretch muscles that have tightened as a result of spasm, and realign the spine. It is helpful for treating painful conditions such as osteoarthritis, herniated discs, bone spurs, sciatica, pinched nerves and degenerative disc disease.
During cervical (neck) spine traction, steady or intermittent force is applied to the neck manually or mechanically. The manner of traction, how much force is used, and how long you should remain in traction, depends on your condition.
During lumbar (lower back) spine traction, you lie on a motorized table. A harness is fastened around your hips. The upper half of the table is fixed, while the lower half of the table slides back and forth producing traction.
Traction may include 15-30 sessions, spread over a 4-6 week period.
Traction is not recommended when the structure of the spine is compromised such as in osteoporosis, tumors or cervical rheumatoid arthritis.
Cervical braces are external devices used to provide support and restrict movement of the cervical spine in a variety of cervical conditions ranging from muscle spasm to severe spine instability or post-surgery. Braces are also called orthotics and are made from different materials such as nylon, rubber, molded plastic and elastic cotton. The basic function of the brace is to:
- Immobilize the spine to aid healing
- Stabilize the injured area
- Manage pain by limiting the movement
Basically braces are of two types, soft and hard braces. Soft braces provide support to the muscles and allows free movement while hard braces limit the movement of the neck. Based on the level of neck being supported by the brace, cervical braces can be categorized into four classes:
- Collar: it extends from the head to the upper region of the thorax
- Posture brace: it is more rigid then a collar and supports the mandibular and occipital region
- Cervicothoracic brace: this type extends further down to the trunk region
- Halo ring: it provides rigid fixation of the head
The strength of cervical bracing depends upon the type of movement being restricted (i.e. flexion, lateral bending, extension and rotation), along with consideration for the patient’s comfort and compliance such as eating or swallowing problems.
Brace specialists are referred to as orthotists and are trained in different fields such as anatomy, biomechanics, material engineering, physical science and other related fields. In some cases, braces are fitted in consultation with an orthotist based on the requirements of the treatment and condition of the patient. Your doctor may recommend the specific time-period for wearing the brace, which may range from weeks to months, depending on the condition and the type of disorder. Physical therapy may also be recommended along with braces.
Patients wearing cervical braces should avoid activities that put undue strain on the affected area such as driving. Follow the instruction of your doctor for bathing and performing other daily activities. If the patient is instructed to shower with the brace, then the brace should be cleaned appropriately following bathing.
Thoracic Spinal Injection
Thoracic facet joints are tiny joints at each section of the spine that impart stability and facilitate guide motion. The facet joints can turn out to be painful due to arthritis of the spine, a back injury or mechanical strain.
Thoracic spine injections are involved in the assessment and treatment of pain in the upper back, chest and rarely, the arm. Acute and chronic pain syndromes from the thoracic spine are much less common than with cervical and lumbar spine. This is valid both for the incidence and the intensity of the disease. Only 2% of the entire painful spinal syndromes influence the thoracic spine.
In the region of the thoracic spine, the vertebral canal is comparatively narrow and there is only a small epidural space between the spinal cord and the osseous surrounding, or the intervertebral disc. The narrowest position is located between TH4 and TH9.
Facet joint injections generally have two objectives - to assist in diagnosing the reason and site of pain and also to impart pain relief.
Piriformis Muscle Injection
The piriformis muscle is present in the buttocks, connecting the sacrum to the outer surface of the hip. This muscle enables us to walk and run. The sciatic nerve is a thick, long nerve passing through or below the piriformis muscle. A spasm of the piriformis muscle can compress the sciatic nerve resulting in severe pain (sciatica). The pain is usually felt over the buttocks but may radiate to the back of the thigh and down the leg as well.
A piriformis muscle injection is used to alleviate the spasm and pain in these patients. The injection comprises an anesthetic and a steroid to reduce the spasm. In most patients the pain resolves with 1 or 2 injections, however, 3 injections may be required to achieve complete benefit.
The entire procedure usually takes 15-20 minutes. You will lie on your stomach. A local anesthetic is used to numb the area of injection. Your doctor will insert the needle into the piriformis muscle under fluoroscopic guidance. A small amount of contrast dye is injected to guide the doctor in proper placement of the needle. After confirming the position of the needle, a steroid-anesthetic mix is injected into the piriformis muscle. After injecting the medication, the needle is removed, and the injection site is covered with a band-aid.
After the Procedure
Following the procedure, you may experience nausea, sweating, and/or dizziness. You may also develop weakness or numbness in the leg for a few hours. You may also notice a slight swelling, redness, bruising, and tenderness at the injection site, which may subside within a short period of time. Once the physician has confirmed that you are stable, you will be discharged to go home. Additional instructions and a follow-up appointment will be given to you at the time of your discharge.