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Pain
Management
Guidelines for treating pain are often ignored. For
a review, see: Epidural Steroid Injections (ESIs): injections are given
in the spine around (not into) the dural sac that holds spinal fluid.
Two randomized, double-blind studies have shown that ESI’s don’t
reduce the need for surgery in patients with herniated discs. They can
help the acute pain but usually don’t give lasting relief in chronic
pain. There are guidelines for their use. Time should elapse (3-4 weeks)
between injections with a re-evaluation of relief before repeating them.
Three ESIs are about the limit, if no long-lasting relief is obtained.
For more information, see: Facet Injections or Blocks: The facets are little joints
on each side of a vertebra that prevent them from sliding forward. They
normally become arthritic with age. Whether they can cause significant
pain is controversial. There is no diagnostic test for facet pain. If a single facet joint is injected with novocaine correctly
(about 0.3 ml) so that none leaks out around the nerve root and the
pain is relieved, the test is suggestive. To be sure, one injection
with short acting Xylocaine, and another with long acting Marcaine should
give pain relief for the appropriate amount of time. Studies have shown
that up to 30% of patients get relief (placebo effect) with saline injections.
I rarely recommend facet injections or the even more damaging burning
procedure called facet rhizotomy. Selective Nerve Root Block: Local anesthetic is injected carefully around a single nerve root as a test to relieve pain. It can be helpful to find the location of pain when tests are inconclusive. It can be dangerous in the neck because the spinal cord is near by. The spinal cord ends about where the last rib comes off, so injections in the lower back are much safer than in the neck or thoracic area. Most of the time a careful neurologic exam and a good CT or MRI scan will reveal the spinal nerve causing pain. Other Spine
Procedures: Some pain management physicians are treating spine pain
without a referral from a spine specialist. If they have no training
in the diagnosis of spine problems, for example an anesthesiologist,
patients risk being subjected to inappropriate procedures, such as “laser”
disc surgery. Laser disc surgery is a re-tread of intradiscal treatments
going back 30 years to chymopapain injections. I have tried all forms
of intradiscal therapy and it doesn’t work. About half the patients
get better in several months, the natural history of the problem. It
threatens to raise the cost of health care without benefit. For more
information, see: |