Physical therapy and injection therapy are the two most common tools used by a spine center to help patients recover from back or neck pain — without surgery. A physician who fails to use these nonsurgical options may only be increasing the need for surgery. Spine surgery should be the last option to explore.While physical therapy is the safest treatment option, sometimes intense pain prevents a patient from entering physical therapy. Injections can often relieve pain long enough to begin therapy. There are many different injections that can be used including epidural steroid injections, facet injections and trigger point injections which can stimulate healing of weak or damaged connective tissues. Injections can also act as a diagnostic tool by providing a spine specialist with key information and insight into the possible causes of your back or neck pain symptoms.
It is important to remember that injection therapy serves as a means to an end. While passive things like massage or pills may feel good, they don’t change anything with the structure of your back. Physical therapy and customized exercises make the back and neck muscles stronger, more flexible and resistant to future strain and pain.
By inserting pain-relieving medication into the injury site or pain generator, joint pain and/or inflammation surrounding a nerve root can be relieved long enough for a patient to begin working with a physical therapist. Injections essentially act as a bridge on the path of your return to activity.
How do injections work?
When physicians choose to use injection therapy, their ultimate goal is to relieve pain long enough to enable the patient to begin physical therapy.
Relief from such injections can last anywhere from a few weeks to a few months and sometimes longer, especially if therapy is used simultaneously to strengthen muscles in the back. In other cases, an injection may bring patients minimal or no pain relief.
The injection procedure
During an injection procedure you may lay on your stomach to enable the X-ray to visualize your spine. Local anesthetic may be injected into the skin and underlying tissues to reduce discomfort.
Once the anesthetic sets in, the epidural needle is inserted into the epidural space, with the vertebrae serving as “landmarks.” The physician will use a special X-ray image from a C-arm fluoroscopic device to make sure the needle is positioned correctly.
The corticosteroid injection may include a saline solution and/or a local anesthetic. Its dosage, volume and components will vary according to the doctor’s assessment of each individual patient.
Once the needle enters the epidural space, a syringe containing corticosteroid solution is connected to it. After ensuring the needle is in the correct place, the solution is slowly injected. During this time, you will be able to communicate with the doctor, and the most common sensation reported is one which resembles the feeling of “pins and needles.”
What are the risks involved?
There are risks involved in any operation or injection procedure. In the case of epidural steroid injections, these risks are minimal. There are a variety of possible side effects and complications, most of which relate to the way in which the injection is administered rather than the actual steroid itself.
The most common side effect of epidural steroid injections is a temporary surge in pain, but this only occurs about one percent of the time and most likely relates to the volume of the injected substance. Headaches are another potential complication, with an incidence of just one percent. These headaches may be linked to the unintended puncture of the innermost membrane that surrounds the spinal cord. In most cases, the headache will subside within a few hours and rarely lasts more than a day.
How many injections will I need?
You are unlikely to benefit from repeated epidural steroid injections if the first or second do not provide relief. You should not receive more than three injections if none of them have helped. Additional epidural injections usually are not indicated if your pain symptoms are increased after an injection. Even if the injections do provide relief, only in exceptional cases will more than three be recommended over a three-month period. Other injection techniques may prove helpful even if the initial approach is not clearly beneficial.
Epidural injections of cortisone may reduce the inflammation and/or swelling of the nerves in the epidural space resulting in decreased pain, tingling and numbness. The procedure involves inserting a needle of a long lasting steroid (cortisone) through the skin and deeper tissues into the epidural space. The epidural space is the area surrounding the spinal cord and the nerves coming out of it. One or more injections may be needed to relieve symptoms.
The facet joints act as the hinges in our back, connecting alll the vertebral bones in our back yet still allowing us to bend and twist with ease. The illustration above shows a facet injection in progress.
Sometimes from injury or age, these joints can become irritated or they can develop bone spurs, which makes movement painful. To relieve pain symptoms and restore range of motion, the spine physician may inject medication into the facet joint. The medicine in a way can act like WD40 on a rusty door hinge, restoring movement. Typically injections are done as a way to bridge the patient to therapy so the therapist can help the patient retain mobility after the effects of the medication wear off.
Trigger Point Injections
Trigger points are painful tissues in and around muscles. Pressure can cause an aching or sharp pain sensation. Trigger point injections are the administration of a local anesthetic and steroid medication in the muscles where pain is occurring. The injection may relieve spasms of the muscle and may last from weeks to months.
Sacro-Iliac (SI) Joint Injections
A long lasting steroid (cortisone) is injected into the sacro-iliac joint to help decrease inflammation and/or swelling of tissue in the joint space. As a result, patients may experience reduced pain and other symptoms caused by inflammation of the joint. The sacro-iliac joint is located in the low back area. The procedure involves inserting a needle through the skin and deeper tissues into the SI joint. More than one injection may be needed for symptom relief.
Rhizotomy is where the physician may use heat or cold to intentionally damage the ability of a problematic nerve to telegraph pain signals to the brain.