One of the most significant advances of the late 20th and early 21st century has been the rise of Interventional Pain Medicine in the treatment of primarily nociceptive pain but also for neuropathic pain.  Interventional Pain Medicine uses predominately injections of the epidural space, facet injections of the spine, sacroiliac injections, radiofrequency neurotomy, disc procedures, spinal cord stimulation, intrathecal infusion pumps, injections of muscles/tendons/peripheral nerves/sympathetic chain/and ligaments.  Many of these are performed under fluoroscopy (x-ray) and should be performed only by physicians- never by CRNAs, Physicians Assistants, Nurse Practitioners, or technicians, even if they are supervised by a physician. They should not be performed by orthopedic spine surgeons or neurosurgeons, family physicians or others without the requisite training and skills to perform these delicate injections.  Insurance companies have stopped covering many interventional procedures because of the sheer numbers of people with chronic pain- over 100,000,000 in the US.  If insurance companies and Medicare/Medicaid paid for procedures, even for only proven effective procedures, it would cause the companies to achieve less profit and stockholders of these companies to derive less dividends.  Therefore, insurers have decided to push patients towards Tylenol, Advil, and prescription opioids, thereby contributing to the opioid epidemic.  At Algos, we offer these procedures as equipment becomes available, regardless of insurance coverage status.  We believe your pain control should not be dictated by the whims of insurers.

​

EPIDURAL INJECTIONS-  since 1901 these were performed without x-ray guidance until around 1995 when interventional pain began performing most of these under fluoroscopy.  Epidural injections place a steroid (or other medication) inside the spinal canal but outside the spinal fluid on the other side of the thick sac containing the spinal fluid (called the dura).  "Epidural" was the word derived from the greek epi (meaning on) and dura (the thick spinal sac containing the fluid).  There are several ways to inject the epidural space:  interlaminar (with a needle passing though the bony window of the lamina (the bone on the back of the spine) and into the epidural space, caudal that is through a small opening in the bone just above the tailbone, and transforaminal (into the neuroforamina where the nerves exit from the spine).  The interlaminar and caudal injections may be performed safely without fluoroscopy in the lumbar and caudal spine as long as the anatomy is easy to recognize and there is no significant spinal stenosis. Transforaminal injections can be performed safely only with fluoroscopy.  Some radiologists do these under CT or MRI but this creates risk of unrecognized arterial vascular uptake of the particulate material that makes up most steroids, and may cause instant paralysis, stroke, or death.  Transforaminal injections in the cervical spine have been performed with ultrasound, but the same risks exist.  Transforaminal injections (injecting where the nerves leave the spine via the neuroforamina) should therefore always be performed under fluoroscopy, period. However the risk of major neurological events is much higher based on the number of case reports, compared to the interlaminar approach.  The outcomes of epidural steroids are highly variable with relief ranging from a few hours to 6 months.  Most obtain relief for 10-60 days if the patient is being treated for a disc herniation with radicular pain (burning, numb pain shooting from the back to the hands for a cervical disc herniation, or foot for lumbar disc herniation).  The results from the interlaminar approach or caudal approach are slightly less than the transforaminal, but with the advantage of less risk of serious neurological events (paralysis, stroke, death).  Epidural injections do not "cure" or "treat" the disc herniation- rather they reduce the inflammation on the nerves produced by enzymes spilling from the herniated disc.  Other substances used in epidural injections include saline, traumeel, sarapin, and non-steroidal anti-inflammatory medications, but 99%+ of all epidural injections use steroids- one of four (Depomedrol/methylprednisolone, Kenalog/triamcinolone, Celestone/betamethasone, Decadron/dexamethasone).

 

FACET INJECTIONS- The facet joints are paired joints located behind the spinal canal that may become painful due to arthritis, compression (disc space narrowing transfers body weight to these joints), or injury (disruption of the capsule or cartilage).  There are two types of facet injections: medial branch blocks and intra-articular injections.  The medial branch block is a diagnostic block that temporarily reduces pain (for several hours) if the pain is emanating from the facet joints by injection of a local anesthetic on the small nerve (medial branch) that .  A successful medial branch block is usually followed by a radiofrequency neurotomy that results in much longer pain relief.  The intra-articular block is placement of the needle into the capsule surrounding the facets or into the facet joint proper, and injected a steroid, giving weeks to months of pain relief.  While intra-articular blocks are not necessarily diagnostic, they are used that way by some physicians.  Medial branch block injections are ideally performed using x-ray fluoroscopy to guide the needle and assure the medication is not going into the spinal canal or blood vessels, however some will use ultrasound or CT scan to do these injections.  The risks of facet injections are less than epidural injections.  Some insurance companies are no longer covering facet injections, instead forcing patients to suffer. 

 

SACROILIAC INJECTIONS-  The sacroiliac joint (SI) is the longest joint in the body, connecting the iliac bone of the pelvis to the sacrum of the spine by a series of ligaments.  The SI joint is only slightly mobile, making it a different type of joint compared to the knee or hip. This joint may become painful due to trauma, infection, arthritis or tumor.  Injections of this joint provide temporary relief, and may be performed under x-ray or ultrasound.  Insurance only covers fluoroscopy or CT guided x-ray, exposing the patient to significant radiation. Some insurance companies are no longer covering sacroiliac injections even though they are an effective treatment for pain.

​

RADIOFREQUENCY NEUROTOMY- Destruction of the nerves that provide innervation to joints is achieved by passage of a high frequency AC current through the area of the nerves causing interruption to the nerves.  Medial branch radiofrequency is performed under x-ray guidance whereas some other radiofrequency may be performed under ultrasound.  Radiofrequency neurotomy may be used only on sensory nerves due to its destructive nature.  The C2 dorsal ganglion, sphenopalatine ganglion, stellate ganglion, superior hypogastric plexus, geniculate nerves to the knee, sacroiliac joint and others are also targets for radiofrequency neurotomy. 

​

DISCOGRAPHY- placement of a needle into the intervertebral disc between the vertebral bodies, and injecting under pressure, reproduces the usual pain from disc related disease. This diagnostic test can be invaluable in determining discogenic disease as the source of pain.  Discography can only be performed using live x-ray fluoroscopy.

​

PULSED RADIOFREQUENCY- Pulsed radiofrequency treatments do not destroy nerves or tissues, unlike radiofrequency neurotomy. This treatment appears to reset the way the neurons transmit and can be used on mixed motor/sensory nerves.  The pain relief received is about 2-3 months.  Pulsed radiofrequency is not covered by insurance, and if it is paid by insurance, it is because your prior pain physician is committing medical fraud by intentionally miscoding the procedure. 

​

CHEMONEUROLYSIS- The use of alcohol, phenol, and other medications can be used to destroy sensory nerves and in some cases, motor nerves.  Injections of these nerves is usually performed under ultrasound guidance.  Insurance is not paying for these injections any longer even though they are quite effective in giving relief lasting 2-12 months. 

​

INTRADISCAL INTERVENTIONS- these include disc decompression procedures for disc herniation such as Dekompressor, Coblation Nucleoplasty, Arthroscopic discectomy, LASE (laser discectomy), APLD, Hydrocision, Selective endoscopic discectomy, etc.   Insurance has blocked payment for all of these procedures that must be performed under x-ray guidance.  IDET, Biacuplasty, Bipolar Intradiscal Radiofrequency, etc are procedures used to destroy the aberrant nerves growing inside the disc in cases of painful degenerative disc disease, and have been shown to be an effective treatment in many studies, but again insurance companies have all blocked these procedures.   

​

CRYONEUROLYSIS- this effective treatment is used to freeze nerves to -60 deg C, causing interruption of the pain being transmitted along these sensory nerves.  It has been used for many decades in the treatment of facet disease, peripheral neuropathy, and entrapment neuropathies.  Insurance companies have blocked payment for cryoneurolysis procedures in the US.  The relief achieved is approximately 3 months. 

​

TRIGGER POINT INJECTIONS- myofascial pain is often muscle derived pain that may manifest itself as a single tender area in a muscle that may be triggering other areas of muscle pain.  Injections of local anesthetic alone or combined with steroids or other substances can lead to dramatic reduction in this type of pain.  

​

LIGAMENT AND TENDON INJECTIONS- the ligaments holding bones together or tendons that connect muscles to bone may develop respectively enthesopathies and tendonopathies.  Injections into these structures bring significant relief to those suffering.  Most interventional pain physicians pay far too little attention to these common disorders, instead focusing on the more lucrative spine injections. 

​

INTRA-ARTICULAR INJECTIONS- Joints are located between bones all over the body.  There are approximately 250 non-fused bones that form joints from the end of the toes to the base of the skull, all with cartilage in the joints, a capsule surrounding the joint, and with the potential to develop arthritis, deformity, subluxation, etc.  Injections of steroids into the joints repeatedly may lead to degrading of the cartilage and acceleration of the joint damage.  Occasional injections do not seem to have this property.  Alternatively injection with saline or one of the homeopathic medicines traumeel, zeel, or sarapin, or the NSAID ketorolac do not seem to cause more damage to the joint.  Saline injections in the knee were found to be equally effective as steroids, thereby reducing the damage to the cartilage (JAMA May 16, 2017)

​

PERIPHERAL NERVE INJECTIONS- Typically injections of nerves cause reduction in both sensory and motor transmission.  In acute pain situations such as trauma or to give anesthesia for surgery, blocking mixed sensory/motor nerves is useful.  However, for chronic pain, generally only sensory nerves are injected.  Some of these include the ilioinguinal, hypogastric, genitofemoral, lateral femoral cutaneous, and others. Local anesthetic blocks may be performed as a diagnostic block followed by a therapeutic chemoneurolysis that gives long term relief.   

​

SYMPATHETIC BLOCKS- The sympathetic nervous system is part of the autonomic nervous system that controls blood vessel tone and contraction, and may be involved with certain disease state pain transmission.  Some of these include the hypogastric plexus for pelvic pain, splanchnic nerves from abdominal pain, stellate ganglion for arm and face pain, and the lumbar sympathetic chain from lower extremity pain.  Conditions such as complex regional pain syndrome (aka reflex sympathetic dystrophy) may be improved through selective blocks of the sympathetic nervous system. 

​

SPINAL CORD STIMULATION- This technology that has been available since 1967 involves placement of trial electrical leads in the epidural space via needles, and temporary (3-7 day) stimulation. If this successfully reduces pain by 50%+ then there may be a consideration for permanent lead implant connected to a spinal cord stimulator generator that is placed under the skin over the back of the illiac crest of the low back.  

​

​

​

​

​