Frequently Asked Questions About Pain Management Center Procedures

Discography is the injection of local anesthetic and dye injected into the disk. Discography is used to determine which disk level(s) is painful, and is usually used as a diagnostic tool for your surgeon. A minimum of two disks will be injected. If you have x-ray findings of disk problems at many levels you may need more disks injected.

Note: The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners. Please make your doctor aware of any of these conditions. This is for your safety!

The main risk of the procedure, though it happens less than one percent of the time, is diskitis. Diskitis is an infection in the disk that can lead to an infection in the spine. Every effort is made to prevent this from happening—antibiotics before the procedure, sterile technique, etc.

There is also a chance of what is called a paresthesia—a shooting, “electric-shock” type pain. This generally occurs when the medicine is injected into the disk and more pressure is put on the nerve. This usually passes quickly but on rare occasion it continues. As with most procedures there is a remote risk of bleeding, infection, nerve injury or allergic reaction to the medications used.

Some short-term side effects may occur. If local anesthetic spreads to nearby nerves you may have weakness or numbness that can last for several hours. If this happens you may have to stay in the Pain Management Center until this resolves. You may have increased pain for a few days after the injection, including localized pain at the injection site.

Your skin will be numbed with a local anesthetic. This is usually felt as a stinging/burning sensation. Once the needle is in the disk, however, it may be painful as the medicine is injected as the goal of the procedure is to try to reproduce your usual pain.

You will need to arrive one hour before your actual injection time so that an intravenous can be started and an antibiotic given. (Let the doctor know if you have any allergies to antibiotics and/or dyes). It takes about 45 minutes for the antibiotic to get to the disk—you will wait in the recovery area during this time (you may want to have your ride keep you company or bring something you enjoy doing—reading, crocheting, etc).

After signing a consent form and checking your blood pressure, the intravenous will be started and the antibiotic given. About 45 minutes to one hour later you will be escorted into the fluoroscopy (x-ray) room. You will be asked to lay on the table on your stomach. The back is cleansed with an antiseptic soap. Sterile drapes are placed. The skin is then anesthetized (numbed) with a local anesthetic. This is felt as a stinging/burning sensation. Using x-ray guidance, the needle is advanced to the appropriate position (into the disk) and local anesthetic and dye are injected. You will be asked to let the doctor know whether or not this causes your usual pain. The needle will then be removed. This process will be repeated at as many levels as needed. Your skin will be cleansed and bandages will be applied. The bandages can be removed on the next morning. Your blood pressure will be checked and you will be discharged to leave with your ride after doctor authorizes your discharge.

It is not unusual to feel sore after the injection. Your usual pain may be somewhat increased after the discography is done. You may experience muscle soreness in your back from the needle placement. This is helped by using ice packs three or four times a day. You may take your usual pain medications after the injection as well.

Do not eat or drink anything for six hours prior to the procedure except for sips of water to take your usual medications. Please follow this instruction unless told differently by your doctor.

You may not drive for the remainder of the day after your procedure. An adult must be present to drive you home or to go with you in a taxi or on public transportation. The procedure will be cancelled of you don’t have a responsible adult with you! This is for your safety.

No heat is to be used in the injected areas for the remainder of the day.

No tub bath or soaking in water (i.e. pool, jacuzzi, etc.) for the remainder of the day.

If you experience severe back pain, new numbness or weakness of your legs or signs of infection in the area of the injection, you should call the Pain Management Center right away at 617-983-7080.

Your first visit is an initial evaluation. This appointment consists of reviewing your medical history, medications, x-rays, treatments already tried and any other pertinent information. Bringing any records you have will help. A physical exam will be performed. A plan of care will be formulated. If an epidural steroid injection is found to be appropriate it will be scheduled as soon as possible. Injections can only be done on the first visit if precertification arrangements have been made with your insurer which allow both an initial visit and a procedure on the same day.

An epidural steroid injection is an injection of local anesthetic and steroid deposited into the epidural space. The epidural space is a space located in the spine just outside of the sac containing spinal fluid. The goal of an epidural steroid injection is to provide pain relief by reducing the inflammation (swelling) of the nerve roots as they exit the spine. An epidural steroid injection will not correct the preexisting medical problem (i.e. spinal stenosis, herniated or bulging disc, arthritis, etc.) but may improve the level of pain. It is not unusual for someone to need more than one injection to get long-term benefit. The injections are done in a series of three injections about a month apart if needed. If the pain is significantly improved no further injection is needed unless the pain begins to come back.

Note: The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners. Please make your doctor aware of any of these conditions. This is for your safety.

The main risk that occurs at a rate of approximately 1/100 is the risk of a dural puncture. This rate is higher in patients who have had previous back surgery. A dural puncture occurs when the needle is unintentionally advanced one layer beyond the epidural space and punctures the membrane that surrounds spinal fluid. If this occurs there is a risk of developing a spinal headache, which may be severe and may last for days. There is a procedure (epidural blood patch) that can treat the headache if it occurs and does not improve sufficiently in 48 hours.

Other risks are remote but include bleeding, infection, nerve injury and allergic reaction to the medication.

Some short-term side effects may occur. If local anesthetic spreads to nearby nerves you may have weakness or numbness that can last for one to two hours. If this happens you will have to stay in the Pain Management Center until this resolves. You may have increased pain for a few days after the injection. Diabetics may have short-term elevation of blood sugars. People prone to fluid retention may have increased fluid retention for one to two weeks.

Most people say the stinging/burning of the numbing medicine is the most uncomfortable part of the procedure though every person’s response to any procedure is individual.

After signing a consent form and checking your blood pressure, the procedure will be done in the sitting position. For procedures in the neck, an intravenous is started. The back or neck is then cleansed with an antiseptic soap. A sterile drape is placed. The skin is anesthetized (numbed) with a local anesthetic. This is felt as a stinging or burning sensation. The needle is then advanced into the epidural space. Pressure is the usual sensation felt—if pain is felt, more local anesthetic will be used. Once in the epidural space the medication is infused and the procedure is complete. Your skin will be cleansed and a bandage will be applied. The bandage can be removed on the next morning. Your blood pressure will be checked and you will be discharged to leave with your ride after the doctor authorizes discharge.

Most people don’t feel any different immediately after the injection though the pain may be temporarily improved or worsened. The steroid takes two or three days to start to have an effect in most people and peaks in about two weeks. Therefore, it may be awhile before you feel a change in your pain.

Some local tenderness may be experienced for a couple of days after the injection. Using an ice pack three or four times a day will help this. You may take your usual pain medications as well after the injection.

You may not drive for the remainder of the day after your procedure. An adult must be present to drive you home or to go with you in a taxi or on public transportation. The procedure will be cancelled if you don’t have a responsible adult with you! This is for your safety.

No heat is to be used in the injected area for the remainder of the day.

No tub bath or soaking in water (i.e. pool, jacuzzi, etc.) for the remainder of the day.

You may eat, drink and take your medications as usual on the day of the procedure (both before and after) unless told otherwise by your doctor.

If you experience severe back pain, new numbness or weakness of your legs, loss of control of your bladder or bowels or signs of infection in the area of the injection, you should call the Pain Management Center right away at 617-983-7080.

A facet block is an injection of local anesthetic and steroid into a joint in the spine. A medial branch block is similar but the medication is placed outside the joint space near the nerve that supplies the joint called the medial branch (steroid may or may not be used). You may require multiple injections depending upon how many joints are involved.

Facet blocks and medial branch blocks are typically ordered for patients who have pain primarily in their back coming from arthritic changes in the facet joints or for mechanical low back pain.

A facet block or medial branch block may be therapeutic and/or diagnostic. One of three things may happen:

1. The pain does not go away—which means that the pain is probably not coming from the blocked facet joints—this has diagnostic value.
2. The pain goes away and stays away for a few hours but the original pain comes back and doesn’t get better again. This would mean the block was also of diagnostic value—the pain is probably coming from the joints, but the steroid was not of benefit.
3. The pain goes away after the block, the pain may come back later that day, but then the pain gets better again over the next few days. This means that the block was of therapeutic value—the steroid had a long-lasting effect on the pain.

If you get good, lasting benefit from the injections, the block may be repeated. If you get good, short-term benefit another procedure (radiofrequency lesioning) may be done which may last months to years.

Note: The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners. Please make your doctor aware of any of these conditions. This is for your safety.

As with most procedures there is a remote risk of bleeding, infection, nerve injury or allergic reaction to the medications used.

Some short-term side effects may occur. If local anesthetic spreads to nearby nerves you may have weakness or numbness that can last for several hours. If this happens you may have to stay in the Pain Management Center until this resolves. You may have increased pain for a few days after the injection, including localized pain at the injection site. Diabetics may have short-term elevation of blood sugars. People prone to fluid retention may have increased fluid retention for one to two weeks.

Most people say the stinging/burning of the numbing medicine is the most uncomfortable part of the procedure though every person¹s response to any procedure is individual.

After signing a consent form and checking your blood pressure, the procedure will be done in the fluoroscopy (x-ray) room with you lying on your stomach. For procedures in the neck, an intravenous is started. The back is then cleansed with an antiseptic soap. Sterile drapes are placed. The skin is anesthetized (numbed) with a local anesthetic. This is felt as a stinging or burning sensation. Using x-ray guidance, needles are then advanced to the appropriate locations (the joints or the medial branch).

Once the needles are in the proper location, local anesthetic with or without steroid is injected through the needles and the needles are removed. Your skin will be cleansed and bandages will be applied. The bandages can be removed on the next morning. Your blood pressure will be checked and you will be discharged to leave with your ride after your doctor authorizes discharge.

Your back pain may be improved immediately after the injection from the local anesthetic. It is important to keep track of how you feel for the remainder of the day. The steroid, when used, takes two or three days to have on effect in most people and peaks in about two weeks.

Some local tenderness may be experienced for a couple of days after the injection. Using an ice pack three or four times a day will help this. You may take your usual pain medications as well after the injection.

It is important that you keep track of the amount of pain relief you received as well as how long the pain relief lasted.

You may not drive for the remainder of the day after your procedure. An adult must be present to drive you home or to go with you in a taxi or on public transportation. The procedure will be cancelled if you don’t have a responsible adult with you! This is for your safety.

No heat is to be used in the injected areas for the remainder of the day.

No tub bath or soaking in water (i.e. pool, jacuzzi, etc.) for the remainder of the day.

If the injections are in your neck, you may take your medications as usual with a sip of water but do not eat or drink for six hours before the procedure. You may eat, drink and take your medications as usual on the day of the procedure (both before and after) if the injections are to be in your low back. Please follow the above instructions unless told differently by your doctor.

If you experience severe back pain, new numbness or weakness of your legs or signs of infection in the area of the injection, you should call the Pain Management Center right away at 617-983-7080.

A root block is an injection of local anesthetic and steroid injected under x-ray guidance into the area where the nerve exits the spinal column. A root block is usually ordered by your doctor for pain in the arm or leg that follows the path of a single nerve.

A root block may be diagnostic and/or therapeutic. One of three things may happen.

1. The pain does not go away—which means that the pain is probably not coming from the nerve at the level of the injection—this has diagnostic value.
2. The pain goes away and stays away for a few hours but the original pain comes back and doesn’t get better again. This would mean the block was also of diagnostic
   value—the pain is probably coming from the nerve at the level of the injection, but the steroid was not of benefit.
3. The pain goes away after the block, the pain may come back later that day, but then the pain gets better again over the next few days. This means that the block was of therapeutic value—the steroid had a long-lasting effect on the pain.

If you get good, lasting benefit from the injection, the block may be repeated. Sometimes your surgeon will ask that the block be done to help identify whether or not surgery might be helpful and at what level the surgery might be most helpful.

Note: The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners. Please make you doctor aware of any of these conditions. This is for your safety.

As with most procedures there is a remote risk of bleeding, infection, nerve injury or allergic reaction to the medications used.

Some short-term side effects may occur. You should get some numbness that follows the path of the nerve that was blocked. You may get some weakness as well. If you get weakness that interferes with your ability to walk, you will have to remain in the Pain Management Center until this resolves—usually several hours. You may have increased pain for a few days after the injection, including localized pain at the injection site. Diabetics may have short-term elevation of blood sugars. People prone to fluid retention may have increased fluid retention for one to two weeks.

Most people say the stinging/burning of the numbing medicine is the most uncomfortable part of the procedure though every person’s response to any procedure is individual. As the injection is right near a nerve it is possible to get a temporary “electric-shock” sensation.

After signing a consent form and checking your blood pressure the procedure will be done in the fluoroscopy (x-ray) room with you lying on your stomach. For procedures in the neck, an intravenous is started. The back is the cleansed with an antiseptic soap. Sterile drapes are placed. The skin is anesthetized (numbed) with a local anesthetic. This is felt as a stinging or burning sensation. Using x-ray guidance, the needle is advanced to the proper location. A dye may be injected at this point (please let the doctor know if you have allergies to dye). Local anesthetic and steroid are then injected through the needle and the needle is removed. Your skin will be cleansed and a bandage will be applied. The bandage can be removed the next morning. Your blood pressure will be checked and you will be discharged to leave with your ride after your doctor authorizes discharge.

Your pain may be improved immediately after the injection from the local anesthetic. It is important to keep track of how you feel for the remainder of the day. The steroid usually takes two or three days to have an effect in most people and peaks in about two weeks.

Some local tenderness may be experienced for a couple of days after the injection. Using an ice pack three of four times a day will help this. You may take your usual pain medication as well after the injection.

It is important that you keep track of the amount of pain relief you received as well as how long the pain relief lasted.

You may not drive for the remainder of the day after your procedure. An adult must be present to drive you home or to go with you in a taxi or on public transportation. The procedure will be cancelled if you don’t have a responsible adult with you. This is for your safety.

No heat is to be used in the injected area for the remainder of the day.

No tub bath or soaking in water (i.e. pool, jacuzzi, etc.) for the remainder of the day.

If the injections are in your neck, you may take your medications as usual with a sip of water but do not eat or drink for six hours before the procedure. You may eat, drink and take your medications as usual on the day of the procedure (both before and after) if the injections are to be done in your low back.

Please follow the above instructions unless told differently by your doctor.

If you experience severe back pain, new numbness or weakness of your legs or signs of infection in the area of the injection, you should call the Pain Management Center right away at 617-983-7080.

A stellate ganglion block (sympathetic block) is an injection of local anesthetic into the front of the neck that is typically ordered by your doctor for pain located in the head, neck, chest or arm caused by sympathetically maintained pain (reflex sympathetic dystrophy), causalgia (nerve injury), herpes zoster (shingles) or intractable angina. Stellate ganglion blocks are also used to see if blood flow can be improved in circulation problems typically from Raynaud’s or CREST.

Stellate ganglion blocks may be therapeutic and/or diagnostic. One of three things may happen:

1. The pain does not go away and there is other evidence of a sympathetic block—the pain is not responsive to sympathetic blocks—this is of diagnostic value.
2. The pain does not go away and there is not good evidence of a sympathetic block—the block is a technical failure.
3. The pain goes away after the injection and stays away longer than the life of the local anesthetic—the block was of therapeutic value. The procedure will most likely have to be repeated to get long lasting benefit. The spacing of injections will be based on how long the pain relief is between injections (usually you will get longer benefit after each injection).

The risks of the procedure, though infrequent, include seizure—if the medication is injected into a blood vessel; pneumothorax (collapsed lung); brachial plexus block (numb arm that lasts for hours); spinal or epidural block (temporary weakness or numbness from the neck down); allergy to medication, nerve damage and bruising at the injection site.

There are some expected changes that result from blocking the sympathetic nerves. These changes last for the life of the local anesthetic (about four to six hours). They include drooping of the eyelid on the injected side, “bloodshot eye” on the injected side, stuffy nose on the injected side and a temperature increase on the injected side. You may also get hoarseness.

The doctor has to press on your neck to locate the area to be injected. Many patients find this awkward and somewhat uncomfortable. The injection itself is done using a very small needle. The local anesthetic stings/burns going in.

After signing a consent form and checking your blood pressure, an intravenous will be started. Skin temperature monitors will be placed on both your hands. You will be asked what your pain score is on a scale of 0 to 10. The procedure will be done with you lying on your back with a sheet rolled up between your shoulder blades. Your neck will be cleansed with an antiseptic soap. The doctor will press on your neck to identify where to place the needle. At this time we’ll ask that you try not to talk, cough or swallow. When the needle is in the correct place, the medicine (local anesthetic) is put in through the needle. The needle is removed and the procedure is complete. This usually takes about five to ten minutes. If your pain is usually in your head, you will remain lying down; if your pain is usually in your arm, you’ll be asked to sit up so the medicine spreads down. The medicine can take ten to twenty minutes to take full effect. You will be watched during that time. Your doctor will be checking to see if the expected changes take place as well as see what effect if any there is on your pain. Your pulse and blood pressure will be checked. If all is well, your intravenous will be removed. You doctor will authorize your discharge when you’re ready and your ride is present.

Your neck may be tender or bruised feeling after the injection. One eye will be droopy. This may affect your sense of balance. You may get hoarseness. If you do you must be careful swallowing.

If your arm gets numb or heavy, you will have to protect it (sling) until sensation returns—usually four to six hours. You may take your usual pain medications after the injection.

It is important that you keep track of the amount of pain relief you received as well as how long the pain relief lasted.

You may not drive for the remainder of the day after the procedure. An adult must be present to drive you home or to go with you in a taxi or on public transportation. The procedure will be cancelled if you don’t have a responsible adult with you. This is for your safety.

Be careful swallowing after the injection (sips of water first) especially if you get hoarseness.

If you experience new shortness of breath 24 to 48 hours after the injection or any signs of infection in the area of the injection, you should call the Pain Management Center right away at 617-983-7080.