Trigger Point Injections
Trigger points may be formed after acute trauma or by repeated micro-trauma, leading to stress on muscle fibers. Trigger point injections are a therapeutic modality to treat myofascial trigger points, especially in symptomatic patients, and have been demonstrated effectiveness to inactivate trigger points. They are believed to cause a temporary relaxation of the taut muscle cord, which in turn allows for improved perfusion, ATP replenishment to release the actin-myosin chains causing lengthening of the muscle fiber, along with removal of metabolite waste. These factors assist in breaking the pain-tension cycle. Trigger point injections can be the patient’s primary therapy, alongside muscle relaxants, and other medications aimed at decreasing pain in the musculoskeletal system. Indications for trigger point injections include identifiable palpable tender area that produces a referred pain pattern. Common concomitant symptoms include chronic or episodic headaches, temporomandibular joint pain, back pain, decreased range of motion secondary to trigger points, and groin pain.

Platelet Rich Injections (P.R.P.)
Platelet-rich plasma (PRP) therapy uses injections of a concentration of a patient’s own platelets to accelerate the healing of injured tendons, ligaments, muscles and joints. In this way, PRP injections use each individual patient’s own healing system to improve musculoskeletal problems. PRP injections are prepared by taking anywhere from one to a few tubes of your own blood and running it through a centrifuge to concentrate the platelets. These activated platelets are then injected directly into your injured or diseased body tissue. This releases growth factors that stimulate and increase the number of reparative cells your body produces. Platelet-rich plasma has been found to significantly enhance the healing process, and using a PRP injection for shoulder pain caused by rotator cuff tears, for Achilles tendon ruptures and for other soft-tissue injuries is becoming more common. PRP has also been demonstrated to improve function and reduce pain in people who have tendonitis or chronic tendinosis conditions such as tennis elbow or golfer’s elbow. Some of the key advantages of PRP injections are that they can reduce the need for anti-inflammatories or stronger medications like opioids. In addition, the side effects of PRP injections are very limited because, since the injections are created from your own blood, your body will not reject or react negatively to them.

Botox Therapy
Botox injections are used to treat conditions such as neck spasms, excessive sweating, an overactive bladder, lazy eye, and may also help prevent chronic migraines. Botox injections use a medication to temporarily prevent a muscle from moving. The injections work by weakening or paralyzing certain muscles or by blocking certain nerves. The effects last about three to twelve months, depending on what you are treating. The most common side effects are pain, swelling, or bruising at the injection site. You could also have flu-like symptoms, headache, and upset stomach. Injections in the face may also cause temporary drooping eyelids. You should not use Botox if you are pregnant or breastfeeding. Doctors use Botox injections in small doses to treat health problems, including temporary smoothing of facial wrinkles and improving your appearance, severe underarm sweating, a neurological disorder that causes severe neck and shoulder muscle contractions, uncontrollable blinking, misaligned eyes, chronic migraine, and patients who have an overactive bladder.

Epidural Steroid Injections
An epidural steroid injection (ESI) is a minimally invasive procedure that can help relieve neck, arm, back, and leg pain caused by inflamed spinal nerves due to spinal stenosis or disc herniation. Medicines are delivered to the epidural space, which is a fat-filled area between the bone and the protective sac of the spinal nerves. Pain relief may last for several days or even years. The goal is to reduce pain so that you may resume normal activities and a physical therapy program.
There are several types of ESIs:

• Cervical ESI (neck). The needle entry site is from the side of neck to reach the neural foramen, just above the opening for the nerve root and outside the epidural space (Fig. 2). Contrast dye is injected to confirm where the medication will flow.
• Lumbar ESI (low back). The needle entry site is slightly off midline of the back to reach the nerve canal (Fig. 3). Contrast dye is injected to confirm where the medication will flow.
• Caudal ESI (tailbone). The needle is placed in the sacral hiatus above the tailbone to reach the lowest spinal nerves. Contrast dye is injected to confirm where the medication will flow.

When the needle is correctly positioned, the anesthetic and corticosteroid medications are injected into the epidural space around the nerve roots. The needle is then removed. Depending on your pain location, the procedure may be repeated for left and right sides. One or several spinal levels may be injected. Patients with pain in the neck, arm, low back, or leg (sciatica) may benefit from ESI. Specifically, those with the following conditions: spinal stenosis, spondylolisthesis, herniated disc, degenerative disc, and sciatica.

Caudal Steroid Injections
A caudal injection is a steroid injection into your low back. The shot goes into the lower part of your epidural space (sleeve-like area that surrounds your nerve roots). The injection contains a steroid medication that reduces inflammation and decreases low back pain. A caudal injection treats nerve pain and inflammation. Causes of nerve pain and inflammation may include: spinal canal stenosis, failed back syndrome or post laminectomy syndrome, herniated disks, degenerative disk disease, and sciatica or radiculopathy.

Joint Injections
Joint injections are injections of different medications used to temporarily treat joint pain.
Who is it for? Anyone in pain located in their joints.

Sacroiliac Joint Injections
Due to traumatic strain, degenerative changes or some rheumatologic disease, the sacroiliac (SI) joint may become inflamed and painful. In some cases, pelvic obliquity, scoliosis, leg length discrepancy and previous ankle and foot injuries may lead to increased stress on the SI joint and it may become a source of back pain. Approximately 20% of all back pains are related to SI joint. Sacroiliac Steroid Injection is performed to localize the pain generator, reduce lower back pain, improved flexibility, enhance function, enabling patient to pursue physical therapy and return to work or activities. A sacroiliac joint injection (SIJI) is a shot of an anti-inflammatory medication and an anesthetic into the joint capsule of the SI joint to treat the pain in your low back, buttock, or upper leg. The goal of this injection is to improve your spine motion as well as provide pain relief.

Intra-Articular Facet Joint Injections
Facet injections are used to reduce the inflammation and swelling of tissue in and around the facet joint space. This may in turn reduce pain and other symptoms caused by inflammation or irritation of the facet joint and surrounding structures. Usually we think of facet joint pain as primarily spine pain, though in some patients there can also be referred pain into the surrounding tissues and even into arms or legs. An intra-articular injection is a type of shot that’s placed directly into a joint to relieve pain. A lumbar intra-articular injection is an injection of an anti-inflammatory medication and an anesthetic into the joint capsule of the facet joint to treat the pain in your lower back. The goal of this injection is to improve your spine motion as well as provide pain relief. The major indications for facet injections include strong clinical suspicion of the facet syndrome, focal tenderness over the facet joints, low back pain with normal radiological findings, post-laminectomy syndrome with no evidence of arachnoidids or recurrent disc disease, and persistent low back pain after spinal fusion.

Facet Medial Branch Blocks
A facet block is an injection of local anesthetic and steroid into a joint in the spine. A medial branch block is similar, but the medication is placed outside the joint space near the nerve that supplies the joint called the medial branch (a steroid may or may not be used). Facet blocks and medial branch blocks are typically used for patients who have pain primarily in their back coming from arthritic changes in the facet joints or for mechanical low back pain. A medial branch block is a type of spinal injection to temporarily block the pain signals coming from the medial nerves. A medial branch block can provide temporary pain relief, but is mostly a diagnostic tool to determine the source of your back pain and the next steps in your treatment plan. An initial diagnostic facet medial branch block is considered medically necessary to determine whether chronic neck or back pain is of facet joint origin. Facet blocks and medial branch blocks are typically used for patients who have pain primarily in their back coming from arthritic changes in the facet joints or for mechanical low back pain.

Radiofrequency Ablation (Neurotomy)
Radiofrequency neurotomy uses heat generated by radio waves to target specific nerves and temporarily turn off their ability to send pain signals. The procedure is also known as radiofrequency ablation. Needles inserted through your skin near the painful area deliver the radio waves to the targeted nerves. Your doctor will use imaging scans during radiofrequency neurotomy to make sure the needles are positioned properly. Radiofrequency neurotomy is most commonly used for pain in the back, neck and buttocks (sacroiliac joint). It may also be helpful for long-term knee or hip joint pain. Radiofrequency ablation uses an electric current to heat up a small area of nerve tissue to stop it from sending pain signals. It can provide lasting relief for people with chronic pain, especially in the lower back, neck and arthritic joints. Radiofrequency neurotomy is usually done by a doctor who specializes in treating pain. The goal is to reduce chronic back, neck, hip or knee pain that hasn’t improved with medications or physical therapy, or when surgery isn’t an option. For example, your doctor may suggest the procedure if you have back pain that: occurs on one or both sides of your lower back, spreads to the buttocks and thighs (but not below the knee), feels worse if you twist or lift something, and feels better when you’re lying down. Radiofrequency neurotomy might also be recommended to treat neck pain associated with whiplash.

Intercostal Nerve Blocks
An intercostal nerve block is a block of nerves that lie underneath the lower edge of each rib. For certain types of injuries, e.g., rib fractures, nerve injuries to the chest wall, postoperative pain along the rib nerves (“intercostal nerves”), injection of a small amount of local anesthetic can significantly diminish pain. An intercostal nerve block is an injection of medication that helps relieve pain in the chest area caused by a herpes zoster infection (or “shingles”) or a surgical incision. Intercostal nerves are located under each rib. When one of these nerves or the tissue around it gets irritated or inflamed, it can cause pain. Intercostal blocks are useful in relieving post-traumatic and postoperative pain, and more recently, chronic nonmalignant and from malignancies processes involving the thoracic wall. 2, 3, and 4 Blockade of the intercostal nerve may ameliorate painful nerve impulses associated with chronic neuropathic pain.

Lumbar Sympathetic Block
A lumbar sympathetic block is an injection of medication that helps relieve lower back or leg pain (sciatica). It can be used to treat: Herpes zoster infection (shingles) involving the legs. Sympathetic nerves are located on both sides of your spine, in your lower back. Specifically, lumbar sympathetic blocks can be used for the treatment of painful conditions such as complex regional pain syndrome, phantom limb pain, hyperhidrosis, painful vascular insufficiencies, and pain from herpes zoster/shingles.

Stellate Ganglion Sympathetic Block
A sympathetic nerve block involves injecting medicine around the sympathetic nerves in a lumbar or cervical area. By doing this, the system is temporarily blocked in hopes of reducing or eliminating pain. If the initial block is successful, then additional blocks are generally repeated and repeated until the pain diminishes. Stellate ganglion block is used primarily to treat Complex Regional Pain Syndrome, but has also been used to treat refractory angina, phantom limb pain, and/ or hyperhidrosis.

Selective Nerve Root Block
A selective nerve root block (SNRB) is the injection of a local anesthetic along a specific nerve root. This procedure is used primarily to diagnose nerve root compression. SNRB injections are isolated to various locations along the spine to determine which nerve root is causing the pain. If the patient’s pain dissipates after the injection at a nerve root, it can be inferred that the source of pain was being generated at the selected nerve root. Along with acting as a diagnostic tool, SNRBs can alleviate the discomfort associated with nerve root compression when used with an injectable steroid. A selective nerve block is performed by injecting a local anesthetic adjacent to vertebral foramina along the spine from which nerve roots emerge. Prior to the block being administered, the site is anesthetized with a local anesthetic. Patients may feel some mild radiating pain as the medication is injected adjacent to the affected nerve root. The procedure itself only takes 15-30 minutes to perform. You will be observed in the recovery room for 20-60 minutes after the procedure. Selective nerve root block injections are used to treat an inflamed nerve root caused by a herniated disc, degenerative changes in the vertebrae such as bone spurs causing nerve compression, and/or conditions such as scoliosis. In any of these conditions, there may be a chemical irritation or pinching of the nerve due to mechanical compression.

Sphenopalatine Ganglion Block
A nerve block is a procedure to stop pain transmission through anesthesia to the nerve. In an SPG block, an anesthetic agent is administered to the collection of nerves in the ganglion. The least invasive way to access the SPG is through the nose. Recently, a device that administers laser therapy to the SPG has been developed to reduce pain for migraine and cluster headache patients. The device produces a nerve block through a laser that is emitted from a probe inserted into the nose. The treatment is relatively non-invasive and takes minutes to administer to each nostril. The risks of the procedure are typically minimal. They include discomfort during and after the procedure, a numb sensation when swallowing, bitter taste from the anesthesia, bleeding from the nose, and light-headedness. These side effects typically resolve within minutes to a few hours. There is a very small risk of seizures, infection, and allergic reactions. The indications for a sphenopalatine ganglion block are patients who have cluster headaches, migraines, trigeminal neuralgia, herpes zoster, paroxysmal hemicrania, cancer of the head or neck, facial pain, complex regional pain syndrome (CRPS), temporomandibular disorder, nasal contact point headache, and/or vasomotor rhinitis.

Celiac Plexus Block
A celiac plexus block relieves severe abdominal pain caused by pancreatic cancer. It’s a type of nerve destruction that stops the celiac plexus nerves in the abdomen from sending pain signals to the brain. Some varieties of celiac plexus block provide temporary pain relief, while others offer long-term relief. A celiac plexus block is performed to block the celiac plexus of nerves that go various organs and parts of the abdomen, this may in turn reduce pain in the abdomen. A celiac plexus block is a procedure that damages the celiac nerves so they cannot send pain messages to the brain. It is sometimes used to treat abdominal pain in pancreatic cancer patients. The indications for a celiac plexus block include treatment of intractable intra-abdominal pain, pain in the setting of malignant and benign neoplasms involving the pancreas, biliary tree, retroperitoneal organs, and other abdominal organs.

Superior Hypogastric Plexus Block
A superior hypogastric plexus block is a procedure that provides pain relief by introducing an anesthetic directly to the nerves associated with the pain experienced. It’s also used to diagnose and treat pain in the lower part of the abdomen and the pelvis. Your brain sends information to the body through pathways known as nerves. Nerves also receive information from the body and send it to the proper regions of the brain. The superior hypogastric plexus block is indicated for chronic intractable lower abdominal and/or pelvic pain: gynecologic disorders like endometriosis, pelvic inflammatory disease, and pelvic adhesions, non-gynecologic disorders like interstitial cystitis, irritable bowel syndrome, and/or sympathetically maintained pelvic pain.

Ganglion Impar Block
The ganglion impar block is used to evaluate and treat anorectal pain, perineal pain and/or genital pain. The ganglion impar is a collection of nerve cells next to the tailbone that may be involved in chronic pelvic or anorectal pain. By injecting numbing medicine around the nerves, the cause of your pain can often be identified. Once identified some patients may benefit from repeat injections, sometimes with steroids. It’s used for a variety of health problems that cause pain in the lower pelvis and groin.

Provocative Discogram
A provocative discogram is a diagnostic procedure to help identify which disc (s), if any, are causing pain. The walls of the discs may develop tears or the disc walls may weaken and bulge, both conditions may be a result of age or injury. This may be reported by a patient as sitting intolerance, aggravation of back pain while bending forward, etc. Provocative discography is the procedure performed to reproduce discogenic pain by injecting contrast in the disc.

Percutaneous Disc Decompression
Percutaneous disc decompression is a least invasive spinal surgery procedure that removes a small part of a herniated disc that is irritating a spinal nerve and causing back or leg pain. In this discectomy procedure, patients are under local anesthesia with sedation and comfortable. The skin is anesthetized with lidocaine and a small needle cannula is advanced to the herniated disc under x-ray fluoroscopy. Percutaneous disc decompression is a new technique to treat herniated disc. The patients who benefit most from percutaneous disc decompression are those with a contained herniated disc, a disc that has not ruptured and still contains the gel-like material inside it. The indications for percutaneous lumbar disc decompression include low back and lower extremity pain caused by a symptomatic disc. Internal disc disruptions and disc herniations are common causes of low back and/or lower extremity pain which may become chronic, if not diagnosed and treated.

IDET is a new procedure for discogenic back pain. In IDET procedure, the physician applies controlled heat to the affected disc wall. Heat contracts and thickens the disc material resulting in contraction of the disc wall thus reduction in the bulge of inner disc material. Intradiscal therapy is a minimally-invasive and revolutionary treatment for chronic low back pain. It’s also known as IDET spine therapy or Intradiscal electrothermal therapy. IDET is a safe and effective treatment for herniated discs, and other painful degenerative disc diseases (DDD). IDET is indicated in patients with chronic back pain that does not respond to conservative treatments like medications, rest, activity modifications, physical therapy or appropriate exercise program.

Disc Denervation
Disc denervation is a pain management procedure that treats disc pain by heating the nerve to block pain signal transmission to the brain. Using radiofrequency, the affected nerves are heated and destroyed. This modifies the nerve fibers and blocks the signaling of pain. Disc denervation (DD), which may also be called radiofrequency ablation, is a pain management procedure for treating chronic discogenic pain such as chronic back pain and neck pain. A minimally invasive procedure, disc denervation uses focused electrical energy to heat and destroy the nerve causing pain, blocking the nerve from sending pain signals to the brain. If you suffer from a bulging disc, herniated disc, or degenerative disc disease, your doctor may recommend a disc denervation procedure. This procedure is minimally invasive and is typically completed in less than an hour. This procedure can treat chronic pain caused by a disc condition that is not responding to other treatment.

Nucleoplasty is a minimally invasive, image-guided therapy used to treat back pain and leg pain caused by herniated discs. During nucleoplasty, one of our interventional radiologists uses image guidance to remove a small amount of disc tissue to relieve pressure on the nerves to help reduce pain and restore mobility. The accepted indications for Nucleoplastia are discogenic radicular pain, contained disc herniation according to an MRI scan with intact annulus fibrosis, insufficient response to conservative treatment and absence of a medical emergency as in the case of Cauda Equina syndrome. Patient selection according to those parameters is very important.

Balloon Kyphoplasty
Balloon kyphoplasty is a minimally invasive treatment for spinal compression fractures. Indications for balloon kyphoplasty surgery include: vertebral compression fractures caused by weakened bones in patients with diagnoses such as Metastatic cancer, kidney disease, lymphoma, and multiple myeloma.