Telephone: (336) 538-7180
Toll-Free: (866) 543-5398
Fax: (336) 538-7739
Francisco A. Naveira, M.D.
Board Certified Pain Specialist
Preparing
for ìFast-Trackî procedures
İİİİİ For those
patients undergoing a procedure, please remember
not to eat or drink at least (6) hours before your appointment. If you are
a diabetic, do not take your insulin or your oral hypoglycemics (blood sugar
medicine) until you have had something to eat, after the procedure. Make sure
to tell the nurses that you are a diabetic so that your case can be done early
in the morning, allowing you to eat and take your medicines as soon as
possible. Your other medicines may be taken with a sip of water, on the morning
of your procedure. Family members are
not allowed in rooms during procedures.İ
Also, it is required that you
have someone drive you home after the procedure. The driver most be a responsible adult, capable of physically help you move,
if you were to need it. Having a Taxi does not meet our safety standards. The
person accompanying you should be strong enough to help you, in the event that
your legs become temporarily weak, due to the local anesthetics.
İİİİİİİ Should you eat, drink,
or not have a driver, your procedure will be cancelled and rescheduled. You
should always ask your physician to explain the procedure and its risks, before
the day of the actual procedure. The staff should be able to provide you with
written information about the procedure, before you have it done. You can also
obtain this information by accessing our website at www.ncpainmanagement.com. If
you have any doubts about the proposed procedure, we highly recommend that you
do not have it done until all of these doubts have been properly addressed.
Nevertheless, remember that because the physician has to work on a previously
set time-schedule, properly addressing the issue on the day of the procedure
may consume the allowed time scheduled for that visit, requiring that the
procedure be rescheduled for a later date.
İİİİİİİ Blood thinners should be
stopped prior to the procedure, especially if the proposed
procedure is close to the spine. Prolonged bleeding can lead to hematomas,
which can compress vital structures such as the spinal cord, resulting in
permanent nerve damage and possible paralysis. You should not take aspirin or aspirin containing
medication for at least eleven (11) days prior to a procedure. This includes
baby aspirins. Coumadin, Heparin, Ticlid, Levenox,
and other blood thinners will also need to be stopped. For your own safety, you
should consult the physician who prescribed the blood thinner, to assess the
risks of stopping these medications, even for a short period of time.
İİİİİİİ If you have an active
infection or a Cold, call and reschedule your appointment. Most of
the procedures that we perform, involve the use of steroids. Steroids will
temporarily decrease your immune system defenses, leading to worsening of
existing infections. (e.i.: a simple ìcoldî can
develop into a ìlife-threateningî pneumonia.)
İİİİİİİ If there is any chance of
you being pregnant, you need to let us know. Some of the medications
used may cause birth defects. In addition, some of the procedures that we
perform may involve the use of fluoroscopy (x-rays), which may also cause birth
defects.
İİİİİİİ Plan to take the day of
your procedure and the next one off. Do not make any appointments
after your procedure. Plan to go home and spend it resting. Make arrangements
to have some company at home.
İİİİİİİ You will have an IV started
and some pain medicine and sedation given, prior to your
procedure. This medicine will stay in your system for a couple of hours and
therefore you should not be driving or making any important decisions, which
you may latter regret.
Types of Procedures
Epidural Steroid Injections or
Transforaminal Epidural Steroid Injections
Epidural steroid injections are
generally performed on patients with back and limb pain (neck and arm or low
back and leg). In these conditions inflammation or irritation of the nerve
roots may cause the spine and limb pain. The irritation of these nerve roots
can be caused by arthritic degeneration of the spine, disc herniation, or
irritating chemicals secreted by our own body. A local anesthetic and a steroid
is injected by the physician into the epidural space,
which surrounds the spinal cord and nerve roots. Long-lasting relief ofİ the pain may be
obtained through the use of these treatments. The leg pain that occurs with
disk herniation is believed to be the result of nerve irritation and
inflammation from the release of chemicals from the damaged disks. The deposit
of steroids in the epidural space counters the inflammation and decrease the
pain. Many times the epidural steroid injections are performed in a series of
three, spaced two weeks apart.
Selective Nerve Root Blocks
With the aid of fluoroscopic x-ray
imaging it is possible for the pain physician to place a needle close to the
hole where a specific spinal nerve root comes out ofİ the spine. Injection of a small amount
of local anesthetic and steroid in close proximity to the spinal nerve may be
more effective, as the medicine is placed closer to the pain-generating
site.İ Also it allows the pain physician
to determine the source of the patient's pain. This information can be very
useful if surgery is being considered.
Sacroiliac (S-I) Joint Block
The sacroiliac joint is located in the region of the
low back and buttocks where the pelvis actually joins with the spine. Problems
with these joints may cause pain in the low back, buttocks, abdomen, groin or
legs. A sacroiliac joint injection serves several purposes. First, by placing
numbing medicine into the joint, the amount of immediate pain relief
experienced will help confirm or deny the joint as a source of pain.
Additionally, the temporary relief of the numbing medicine may better allow a
chiropractor or physical therapist to treat that joint. Also, the steroid will
help to reduce any inflammation that may exist within the joint(s). For this
procedure, the patient is placed on the X-ray table on their stomach in such a
way that the physician can best visualize these joints in the back using x-ray
guidance. The skin on the low back is scrubbed using a sterile solution. Next,
the physician numbs a small area of skin with numbing medicine. This medicine
stings for several seconds. After the numbing medicine has been given time to
be effective, the physician directs a very small needle, using x-ray guidance
into the joint. A small amount of contrast (dye) may be injected to insure
proper needle position inside the joint space. Then, a mixture of numbing
medicine (anesthetic) and anti-inflammatory (steroid) is injected. One or
several joints may be injected depending on location of the patientís usual
pain. Immediately after the procedure, the leg(s) may feel weak or numb for a
few hours. This is fairly uncommon, but does occasionally happen.
Facet Joint Block
It is a surprise to many that most back
and leg pain is not due to disk herniation and spinal nerve root irritation. In
the past, failure to recognize this fact, led to a high rate of unnecessary
disk surgery with poor results. In the search for other causes for back pain,
attention has become focused upon the facet joints as a possible source of
pain. Facet joints are paired joints that connect the posterior elements of the
vertebral bodies of the spine. These joints permit the vertebral bodies to
glide over each other while the back is in motion. Throughout life, these
joints are subjected to repetitive strain and it is not uncommon for them to be
affected by minor trauma or arthritis. Pain from these joints can be referred
to the neck, shoulders, upper arm, head, posterior chest wall, hips, thigh,
buttock region, and leg, depending on what level of the spine is affected.
Lumbar facet injections are used for patients with low back pain with or
without leg pain, coming from inflammation of these joints. Similarly, cervical
facet injections can be performed for patients with neck pain and/or headaches,
as a result of problems with these joints. As with epidural steroids, the
relief from facet joint injection may not be permanent. Nevertheless, by
temporarily removing some of the pain, the patient may be able to participate
in physical therapy. Patients scheduled for facet joint injections must have
failed to respond to other conservative treatments, such as rest, lumbar
corsets (back braces), oral anti-inflammatory medications and/or physical
therapy. Facet injections are performed using x-ray guidance. A mixture of a
local anesthetic and a steroid is injected. These injections should not only
provide relief of the pain and inflammation but they should also provide more
diagnostic information to the pain physician. Atİ NC
Pain Management Services, PA,
when the pain recurs after the initial injection, we may be able to provide
longer lasting relief by performing a procedure called facet denervation
(Radiofrequency). The procedure is done in an outpatient setting. The pain
relief after this radiofrequency procedure may last anywhere from 3 to 18
months.
What are the risks, side effects, and possible complications?
Generally speaking, most
procedures are safe. However, with any procedure there are risks, side effects,
and the possibility of complications. The risks and complications are dependent
upon the sites that are lesioned, or the type of nerve block to be performed.
The closer the procedure is to the spine, the more serious the risks are. Great
care is taken when placing the radio frequency needles, block needles, or lesioning probes, but sometimes complications can occur.
1.
Infection: Any time there is an
injection through the skin, there is a risk of infection. This is why sterile
conditions are used for these blocks. There are four possible types of
infection:
I.
Localized skin infection.
II.
Central Nervous System infection ñ this can be in the form of
meningitis, which can be deadly.
III.
Epidural Infections ñ this can be in the form of an epidural abscess,
which can cause pressure inside of the spine, causing compression of the spinal
cord with subsequent paralysis. This would require an emergency surgery to
decompress, and there are no guarantees that the patient would recover from the
paralysis.
IV.
Discitis ñ this is an infection of the intervertebral discs. It occurs
in about 1% of discography procedures. It is difficult to treat and it may lead
to surgery.
2.
Pain: The needles have to go
through skin and soft tissues, which will cause soreness.
3.
Damage
to internal structures: The nerves to be lesioned may be near blood vessels or other nerves
which can be potentially damaged. Please discuss your specific concerns with
your physician.
4.
Bleeding: Bleeding is more common if
the patient is taking blood thinners such as aspirin, Coumadin, Ticlid, Plavix,
etc., or if he/she have some genetic predisposition such as hemophilia.
Bleeding into the spinal canal can cause compression of the spinal cord with
subsequent paralysis. This would require an emergency surgery to decompress and
there are no guarantees that the patient would recover from the paralysis.
5.
Pneumothorax: Puncturing of a lung is a
possibility, every time a needle is introduced in the area of the chest or
upper back.
6.
Spinal
headaches:
They may occur with any procedures in the area of the spine.
7.
Nerve
damage: By
working so close to the spinal cord, there is always a possibility of nerve
damage which could be as serious as a permanent spinal cord injury with
paralysis.
8.
Death: Although rare, severe deadly
allergic reactions known as ìAnaphylactic Reactionî can occur to any of the
medications used.
9. Worsening of the symptoms: We can always make things worse.
Note: Remember that this is not meant to be interpreted as a complete list of all possible complications. Unforeseen problems may occur.
What are the chances of something like this happening?
Chances of any of this occurring are extremely low. By statistics, you have more of a chance of getting killed in a motor vehicle accident, while driving to the Hospital, than any of the above occurring. Nevertheless, you should be aware that they are possibilities.
Who should not have this procedure?
If you are on a blood
thinning medication (e.g. CoumadinÆ, PlavixÆ,
see back), or if you have an active infection going on, you should not have the
procedure. If you have not responded to local anesthetic blocks, you may not be
a candidate for this procedure. If you are taking any blood thinners, please
inform your physician.
How should I prepare for this procedure?
1. Do not eat or drink anything,
at least six (6) hours prior to the procedure.
2. Bring a driver with you.
Cannot be a Taxi.
3. Take all of your medicines
the morning of the procedure, with just enough water to swallow them. If you
have diabetes, do not take your Insulin or your sugar pills (oral hypoglycemics)
until after the procedure.
4. Do not take aspirin or any
aspirin-containing medications, at least eleven (11) days prior to the
procedure. They may prolong bleeding.
5. Do not take any non-steroidal
anti-inflammatory drugs, at least one day prior to the procedure. They may
prolong bleeding.
6. Wear loose fitting clothing
that may be easy to take off and that you would not mind if it got stained with
Betadine or blood.
7. Take a shower the morning of
the procedure, using a bactericidal soap to minimize chances of infection.
8. Do not wear any jewelry or
perfumes.
From
From Raleigh-Durham: Take I-40 West and get off on Exit 141. (
Fast-Track Referral System: This is a service provided to a select group of
physicians, for the purpose of accelerating your treatment. The evaluation and
the decision to proceed with a particular treatment or test, has been made by
your physician. You will be briefly met by a Pain Specialist that will
concentrate in performing the requested procedure. After the procedure, you
will be seen once more by this Specialist, to evaluate the results of the
procedure. After this, you will go back to your physician for continued
management. Your physician will be receiving a description of the procedure and
its results, following the second visit. Although your Pain Specialist may
provide you with some pain medicine to use after the procedure, we will not
be taking over your medications or your pain management, unless
specifically requested by your referring physician in a separate formal
consult.
For more information on other services and conditions,
please visit our website www.ncpainmanagement.com