Pain management procedures

 

Introduction

  • Pain management procedures (PMPs) are usually not a ‘cure’ for chronic pain.
  • However they can provide an effective way to improve your overall pain management.
  • PMPs provide pain relief so other long-term pain treatments have a better chance of working: please see the PainHealth website.
  • PMPs allow you to reduce pain medications & engage more effectively in physiotherapy & behavioural therapies.
  • Sometimes pain procedures can actually ‘switch off’ sensitive nerves & produce long-term pain relief.

 

Pain management procedures list

Low back pain

  • Facet joint steroid injection
  • Facet joint (medial branch) nerve block
  • Facet joint neurotomy
  • Cluneal nerve block
  • Sacroiliac joint steroid injection
  • Sacroiliac joint neurotomy

 Leg pain (sciatica)

  • Epidural steroid injection (nerve-root injection)

Neck pain

  • Facet joint (medial branch) nerve block (C5/6)
  • Facet joint (medial branch) neurotomy (C5/6)
  • Muscle trigger point injections

Headaches & facial pain

  • Occipital nerve block
  • Facet joint (medial branch) nerve block (C2/3)
  • Facet joint (medial branch) neurotomy (C2/3)
  • Sphenopalatine ganglion block
  • Stellate ganglion block
  • Botox injection

Knee pain

  • Knee joint steroid injection
  • Knee joint viscotherapy injection
  • Knee infrapatellar nerve block
  • Adductor canal saphenous nerve block
  • Knee genicular nerve blocks & neurotomies

Hip & thigh pain

  • Hip joint steroid injection
  • Hip joint obturator nerve block
  • Greater trochanteric bursa steroid injection

Shoulder pain

  • Shoulder joint steroid injection
  • Suprascapular nerve block & pulsed radiofrequency treatment

Abdominal wall pain

  • Anterior cutaneous nerve entrapment syndrome (ACNES) block

Pelvic & coccygeal (tailbone) pain

  • Pudendal nerve block
  • Ganglion impar block
  • Coccygeal steroid injection

Nerve pain

  • Intercostal nerve block (ribs pain)
  • Ilioinguinal or genitofemoral nerve blocks (groin or testicle pain)
  • Lateral cutaneous nerve to thigh block (pain in outer thigh)
  • Capsaicin patch therapy (chilli pepper)

Leg pain (poor circulation)

  • Lumbar sympathectomy

Neuromodulation

 

Facet joint steroid injection

  • Facets joints are small stabilizing joints on the outside of the spine.
  • Up to 30% of back & neck pain cases are due to facet joint arthritis.
  • Using an x-ray machine a small amount of local anaesthetic & steroid (cortisone) is injected into the facet joint.
  • Facet joint injections (FJIs) may reduce back or neck pain for weeks-to-months, but their effects are variable.
  • 1-in-5 patients report good reduction in pain following FJI.
  • FJIs are more effective in patients over 60 years of age.

Facet joint (medial branch) nerve block

  • Local anaesthetic is injected around the medial branch nerves coming from the facet joints, to test if these joints are the source of  person’s back or neck pain.
  • If the pain settles after the local anaesthetic injection (usually 4 hours or so) it’s likely the facet joints are causing the pain.

Click here for patient information about facet joint procedures from the Faculty of Pain Medicine.

Facet joint (medial branch) neurotomy

  • Using an x-ray machine a small needle is placed near the medial branch nerves going to the facet joint.
  • Via this needle a tiny electric charge is used to heat (cauterize) the nerve.
  • This procedures is called a facet joint neurotomy (FJN).
  • A FJN may produce long periods (months) of back-or-neck pain relief in 1-in-4 patients.
  • Before performing a FJN, a patient must first report good pain relief after a facet joint injection or nerve block.
  • Pulsed radiofrequency treatment: the nerves are temporarily blocked by electromagnetic pulses sent down the needle.

Click here for more detailed information from PainScience about facet joint neurotomies.

 Cluneal nerve block

  • Low back & buttock pain may be caused by compression of the cluneal nerves as they pass over the top of the hip bone (iliac crest).
  • Using an x-ray machine the cluneal nerves are blocked with a local anaesthetic & steroid injection as they pass over the hip bone.
  • Cluneal nerve blocks may provide back pain relief lasting for months in 1-in-4 patients.
  • Pulsed radiofrequency treatment: the nerves are temporarily blocked by electromagnetic pulses sent down the needle.

Sacroiliac joint steroid injection

  • Sacroiliac joints (SIJ) are the biggest joints in the body.
  • SIJs cause low back & buttock pain in 20% of cases.
  • Using an x-ray machine local anaesthetic & steroid is injected into the SIJ.
  • SIJ injections may help patients with back pain due to inflammatory arthritis (e.g. ankylosing spondylitis).
  • SIJ injections are less effective in patients with joint ‘wear & tear’ or injury (e.g. after childbirth).

Sacroiliac joint neurotomy (rhizotomy)

  • Using an x-ray machine small needles are placed near the nerves going to the sacroiliac joint (SIJ).
  • Via these needles a tiny electric charge is used to heat (cauterize) the nerves.
  • This may produce long periods (months) of pain relief (for low back & buttock pain) in 1-in-4 patients.
  • Before performing a SIJ neurotomy a patient must first report good pain relief from a SIJ injection.

Muscle trigger point injection

  • Sometimes neck, shoulder or low back pain is associated with tight muscle knots called trigger points.
  • Injecting these trigger points with local anaesthetic via a fine needle is sometimes helpful for muscle pain.

Epidural steroid (nerve-root) injection 

  • A protruding spinal disc may irritate a nearby nerve causing leg pain (sciatica).
  • Using an x-ray machine a fine needle is placed into the epidural space next to the irritated nerve.
  • A small amount of local anaesthetic & steroid (cortisone) is injected around the nerve, via the needle.
  • Epidural steroid injections may reduce leg pain (sciatica) for weeks-to-months in 1-in-4 patients.
  • Epidural steroid injections DON’T treat low back pain, only leg pain.

Click here for more information about epidural steroid injections from the Faculty of Pain Medicine.

 Occipital nerve block

  • Many headaches are associated with sensitivity of the nerves in the back of the scalp called the greater & lesser occipital nerves.
  • These nerves are blocked with a local anaesthetic & steroid injection just under the skin of the scalp at the back of the head.
  • Some patients report excellent relief of headaches lasting for months & it’s a relatively low-risk procedure.
  • We sometimes perform C2/3 facet joint steroid injections or nerve blocks in the upper neck to treat headaches.
  • Pulsed radiofrequency treatment: the nerves are temporarily blocked by electromagnetic pulses sent down the needle.

Suprascapular nerve block

  • Using an ultrasound machine to see the path of the needle, local anaesthetic & steroid is injected near the suprascapular nerve as it passes over the shoulder blade.
  • This is a low risk procedure and many patients report good relief of their shoulder pain.
  • Pulsed radiofrequency treatment: the nerve is temporarily blocked by electromagnetic pulses sent down the needle.

Knee joint injections & genicular nerve blocks

  • Steroid are injected into the knee joint to temporarily reduce knee pain.
  • Artificial joint fluid (viscotherapy) can be injected into the knee to improve joint lubrication & reduce pain.
  • Knee pain can also be treated with an infrapatellar nerve block (a small sensitive nerve branch just below the knee cap).
  • Using an x-ray machine the 3 main nerves to the knee (genicular branches) are blocked by performing a neurotomy via a fine needle (cauterizing the nerves).
  • Pulsed radiofrequency treatment: the nerves are temporarily blocked (for days-to-weeks) using electrical pulses via a fine needle.

Hip joint steroid injections & obturator nerve blocks

  • Hip pain may be treated by injecting local anaesthetic & steroid into the joint using an ultrasound or x-ray machine to place the needle.
  • The obturator nerve going to the painful hip can be blocked by performing a neurotomy (cauterizing the nerves) via a fine needle placed near the nerve using an ultrasound or x-ray machine.

Greater trochanteric bursa injections

  • The greater trochanteric bursa is a fluid filled sac that acts as a shock absorber for the tendons & muscles of the thigh.
  • If this bursa or nearby tendons become inflamed, pain can develop in the upper-outer thigh, especially with walking, climbing stairs or rolling in bed at night.
  • Using an ultrasound machine to see the path of the needle, local anaesthetic & steroid is injected near the bursa.
  • This is a simple, fast & low-risk procedure; most patients report good relief of their thigh pain.

 Abdominal cutaneous nerve entrapment blocks

  • Some patients with abdominal pain have a trapped nerve in the muscles of the abdominal wall called the rectus sheath.
  • These trapped nerves can be pinpointed as tender areas in the abdominal wall.
  • Using an ultrasound machine to see the muscles, these nerves are blocked with a local anaesthetic & steroid injection via a fine needle.
  • Sometimes a nerve-dissolving fluid called phenol is injected for longer-lasting pain relief.
  • This is a relatively low-risk procedure which often works well for patients with long-standing abdominal pain.

Pelvic & coccygeal (tailbone) pain procedures

  • Pain in the pelvic region & tailbone (coccyx) is common (especially in younger females) & has many possible causes.
  • Very often however, a specific cause cannot be found.

Ganglion impar block

    • The ganglion impar is a small bundle of nerve fibres located at the tip of the tailbone (coccyx).
    • These nerves transmit pain signals from the the tailbone & pelvis.
    • Some patients develop tailbone pain (coccydynia) after falling heavily on their bottom & fracturing their coccyx.
    • Some patients develop  pain in the pelvis related to nerve pain or cancer.
    • Using an ultrasound machine to see the needle, local anaesthetic & steroid is injected near the ganglion impar nerves via a small needle through the tailbone.
    • Sometimes a nerve-dissolving fluid called phenol is injected for longer-lasting pain relief.

Pudendal nerve block

  •  Pudendal nerves are the two main nerves going from the pubic region (vagina, or penis & scrotum) to the spine.
  •  Sometimes these nerves become trapped in the pelvis & produce nerve pain & numbness in the pubic region.
  •  Using an ultrasound machine to see the path of the needle, local anaesthetic & steroid is injected near the nerves.
  •  The needle is placed through the buttock muscles with the patient laying on their front.

 Other nerve blocks

  • We also perform injections of painful surgical scars, nerve blocks of the groin (groin pain after hernia repair) and intercostal nerves (between the ribs).

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