Pain Procedures in spine and joints:

There are various pain procedures available for various forms of spine and joint conditions. We must understand that each procedure has a scientific basis. Each procedure follows science and so do the results and so should be the expectation from any pain procedure. 

Concept of pain procedures

There are specific anatomical tissue in spine and joints that are responsible for causing pain. These are called pain generators. The pain in turn is carried by ‘nerve’ supplying that specific tissue. Pain procedures use various modalities to target these pain generators or the ‘nerve’ of that pain generator. These modalities are steroid injections, platelet rich plasma (PRP), local anaesthetic agent and radio frequency ablation (RF). The duration of pain relief depends on the modality used, the stage of disease and most importantly the structure targeted, pain generator or the nerve.

Lets understand this with examples:

Example 1: One of the causes of backpain is inflammation of facet joints. Nerve supplying the facet joint is called medial branches of dorsal rami of spinal nerves or simply the medial branch. So facet joint is the pain generator and the medial branch is the nerve carrying pain. We can bring relief to this pain by either targeting the facet joint by injecting steroid that brings 3-6 months of pain relief or by targeting the medial branch by a radio frequency which brings 2.5-3 years of pain relief.

Example 2: Knee pain in osteoarthritis of knee is in part because of synovial inflammation and cartilage degeneration. Nerve supplying the joint are the genicular nerves. We can target the pain generator (synovium and cartilage) by steroid injection that reduces the inflammation and brings relief for 3-6 months depending on the stage of osteoarthritis. PRP injection which is a regenerative therapy can also be given that helps form new healthy cartilage and synovium and brings relief for 9-12 months. Nerve can also be targeted by radiofrequency ablation of the genicular nerves that brings relied for 2.5-3 years. Choice of pain procedure depends on the severity of pain, stage of osteoarthritis and expectations of the patient.

Benefits of spine injections and pain procedures

1. Targeted therapy: Pain procedures pin-point the pain generator or the nerve and are therefore targeted therapies unlike oral medicines that affect the whole body systems. Therefore there is no systemic side effects of these procedures

Example: Epidural steroid injections target the inflamed nerve root only and steroid or PRP              injections target only the specific knee joint where the injection is given.

2. Minimally invasive techniques: These procedures are done using needles under local anaesthesia. There is no incision and minimal or no recovery time and done on OPD basis.

Example: Radiofrequency ablation done for backpain or knee pain uses heat from radio                   waves to turn off pain signals from specific nerves.

3. Diagnostic and therapeutic role: Pain procedure like selective nerve root block and facet injections serve dual purpose, they confirm source of pain (diagnostic) and provide temporary relief (therapeutic). This helps in planning further treatment.

Example: A selective nerve block can identify which nerve is causing pain so that which                 spine level should be targeted in surgery can be planned.

4. Inflammation control: The main cause of pain in herniated discs, spinal stenosis and joints is inflammation around the nerve or in the joints. Steroids are known for their anti-inflammatory role and their injection in the local site thereby brings pain relief.

Example: In selective nerve root block, steroid is injected close to a specific nerve root to reduce inflammation caused by prolapsed disc, similarly sacroiliac joint injections bring down back pain by same mechanism in ankylosing spondylitis.

1. Regenerative techniques: PRP is a centrifuge concentrate obtained from one’s own blood. It contains multiple growth factors namely

• Platelet Derived Growth Factors (PDGF)
• Transforming Growth Factor (TGF-beta)
• Vascular Endothelial Growth Factor (VEGF)
• Epidermal Growth Factor (EGF)
• Fibroblast Growth Factor (FGF)
• Insulin-Like Growth Factor-1 (IGF-1)
• Hepatocyte Growth Factor (HGF)
• Basic Fibroblast Growth Factor (bFGF)

These growth factors aid in forming new healthy tissue that replaces the degenerated tissue and thus promote healing. There result become obvious in around a week’s time but are longer lasting than steroids.

Example: PRP injections in the knee joint help in formation of new cartilage and synovium   and brings pain relief.

6. Nerve ablation techniques: As previously explained, there is a nerve that carries pain from the pain generating structure. Radiofrequency ablation (RF) is a technique that uses heat produced by radio frequency probes set at at a desired wavelength and frequency to selectively damage the pain carrying nerve. It produces a more lasting effect.

Example: Facet joint pain is carried by the medial branch. Medial branch rhizotomy/ablation is done using radio frequency and brings a sustained relief in backpain for 2.5-3 years.

SPINE PAIN PROCEDURES AND CONDITIONS MANAGED

1. Epidural steroid injections:

• Patient selection: Patients with sciatica due to lateral recess disc bulge or lateral recess stenosis benefit the most with epidural injections. Best candidates are the ones who have been suffering from back pain radiating to back of thigh, leg, ankle and foot for few weeks or months.
• Technique: Here a small volume of steroid is injected in the epidural space in the spinal canal. Epidural steroid injection reduce inflammation around the traversing nerve root and brings relief to pain.
• Expected result: Results typically last for 3-6 months. In some cases where intervention is done early, results may last for lifetime.

2. Selective nerve root block (SNRB):

• Patient selection: This technique is also beneficial for patients with sciatica due to foraminal disc bulge and foraminal stenosis.
• Technique: Here a selective exiting nerve root is targeted and injection given close to it. The steroid reduces inflammation around the exiting root and brings pain relief.
• Expected result: Results typically last for 3-6 months. In some cases where intervention is done early, results may last for lifetime.

3. Facet joint injections:

• Patient selection: Predominant backpain in elderly paients that increases on twisting movements of spine is generally arising from facet joints. These patients have no leg pain.
• Technique: Steroid injection is given directly into the facet joint. Steroids reduce the inflammation and brings relief.
• Expected results: Results last only for few weeks or months. Because the result last only a short time, a better option than facet joint injection is medial branch rhizotomy by radio frequency.

4. Medial branch rhizotomy/Radiofrequency ablation(RF):

• Patient selection: Predominant backpain in elderly patients that increases on twisting movements of spine is generally arising from facet joints. These patients have no leg pain.
• Technique: Facet joint pain is carried by medial branches of dorsal rami of spinal nerves or simply the medial branch. This technique damages this nerve, thereby treating the pain. A specialised instrument called radio frequency ablation is used that when set at desired frequency and amplitude produces heat to damage the medial branch.
• Expected result: Results last a minimum of 2.5-3 years after which procedure can be repeated. This technique is therefore better than facet injections.

5. Sacro-iliac joint injections:

• Patient selection: Patients with backpain due to sacroiliac joint inflammation are ideal candidates. Mostly these patients suffer from an genetic arthritis called ankylosing spondylitis. A very important precaution is that any infection of sacroiliac joint is a contraindication for this injection and therefore a proper patient selection is a must. Sacroiliac joint is a part of pelvis and not spine but backpain of sacroiliac joint inflammation can be confused with backpain of spine. Your spine surgeon can differentiate between the two by sing special clinical tests and MRI.
• Technique: Steroid injected directly into the sacroiliac joint reduce inflammation and cause significant relief.
• Expected results: Few sessions of steroid injections may be required from time to time but the relief is drastic and long term.

JOINT PAIN PROCEDURES AND CONDITIONS MANAGED

1. Knee PRP injections:

• Patient selection: Patients with knee pain in early stages of osteoarthritis who don’t want to go for surgery benefit from PRP injections. PRP is a regenerative therapy that helps form new healthy cartilage and synovium and therefore gives long term and promising results.

• Technique: Four shots of PRP centrifuge is directly into the knee, one shot every week. Procedure is done in local anaesthesia and virtually painless.

• Expected results: Results begin to manifest in around a week and lasts for 6-12 months. It should be understood, PRP injection work well in early stages of knee pain. In severe osteoarthritis, radio frequency ablation of genicular nerves is required.

2. Radiofrequency ablation of genicular nerves:

• Patient selection: Patients with pain of advanced knee osteoarthritis who are not willing for knee replacement surgery benefit tremendously with this technique.
• Technique: Genicular nerves namely superior medial nerve, superior lateral nerve and inferior medial nerve carries the pain of knee. They are ablated by radio frequency energies using an instrument called radio frequency ablation. The procedure is performed in local anaesthesia.

• Expected results: The pain relief last for 2.5-3 years after which the procedure can be repeated.

3. Shoulder steroid injections:

• Patient selection: These patients typically have pain in shoulder that increases in night and is associated with restricted shoulder movements. This condition is called frozen shoulder.

• Technique: A small amount of steroid along with local anaesthesia is injected in the shoulder joint and shoulder is immediately mobilised as per patient comfort.
• Expected results: Results start apperaing in a week. If combined properly with physical therapy, there is complete pain relief and restoration of shoulder movements in 1.5-2 months.

4. Bursitis, Tendinitis, Ligament and tendon injuries:

• Patient selection: Patients with pain at insertion site of tendons, or inflammation of bursa etc are candidates for PRP with or without steroids at these local sites. Common conditions include pain in heel (Plantar fascitis and tendo-achillis insertional tendinitis), pain in elbow (tennis elbow), olecranon bursitis, trochantric bursitis etc.
• Procedure: 4-6 sessions of PRP injections with or without steroids is injected directly at the site of pain.
• Expected results: Results appear in a week and when combined with physical therapy are generally long lasting.