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Certain pain conditions respond well to specific injections. Depending on the type of injection, these may be performed in outpatients or require you to attend x-ray or a day case unit. These injections include:
An epidural is an injection into the epidural space. The epidural space runs from the base of the skull to bottom of the spine inside the bony spinal canal. It surrounds the spinal cord and spinal nerves. The nerves from the spinal cord cross the epidural space to run to various parts of the body. The commonest use of epidural injections is with local anaesthetic to provide pain relief for women in labour and sometimes for extra pain relief during major surgery.
Sometimes when patients have neck, back and or leg pain it is thought that some of the nerves may have been irritated as they pass through the epidural space. This can occur with a disc prolapse, arthritis or after surgery on the spine. It is possible to inject the epidural space using a mixture of local anaesthetic and a steroid preparation to try to reduce the irritation and pain. This will allow you to gradually increase your daily activities so strengthening your back, and reduce your painkillers.
The steroid is used in the same way as when steroids are injected into, say, a painful tennis elbow. Unfortunately, no company actually produces a steroid specifically designed for the epidural space. However, using standard orthopaedic preparations epidural injections for back pain have been used since the early 1970s and are considered to be very safe by the national and international pain organisations.
Epidural injections are performed with local anaesthetic in hospital as a day case procedure. After the skin at the injection site has been numbed, a needle is inserted either at the bottom of the spine (a caudal epidural), back or neck depending on which nerves are being irritated. Once the doctor is happy the needle is correctly placed a mixture of local anaesthetic and steroid is injected. Sometimes the doctor will use an X-ray to confirm this.
The local anaesthetic may cause a certain amount of numbness in your buttocks and legs (lumber and caudal epidural). This will only last a few hours. Pain relief can take up to a week or more. This varies between individuals and even in the same person.
Unfortunately, up to a third of people get little benefit from the procedure. The duration of effect is also variable. Some people only get a few weeks relief, others many months. However, any relief gained will be increased if you are more active during this time.
As well as the local anaesthetic numbing the nerves to your legs, it can also temporarily numb nerves that are involved in the control of your blood pressure. This reduction in blood pressure can make you light headed and unsteady on your feet. This is usually remedied by lying down. A drip or medication may be used to bring up your blood pressure but this is rarely necessary. The doctor will often insert a cannula (an intravenous needle) prior to the epidural in case of this eventuality.
About one in every two hundred epidural injections can lead to a small leak of fluid from one of the linings of the spinal canal. This can lead to a headache, which can be severe.
The headache has some unique characteristics and can occur up to a week after the epidural. There is a specific treatment for this headache so if any unusual headache occurs soon after the epidural you should contact the pain team.
There is often an ache for several days at the site of the epidural. However there is very little, if any, evidence of long term backache occurring due to these procedures.
Some people feel flushed and warm for a day or two after the epidural injection.
The sympathetic nerves control many of the automatic functions of the body, such as heart rate, sweating, gut motility and the blood flow to the limbs. They can become involved in pain conditions and maintain the pain syndrome. An injection that blocks the sympathetic nerves to the part of the body affected by the pain can sometimes reduce the pain.
The sympathetic nerves that supply the legs come out of the spinal cord in the thoracic and lumbar regions, and run together in front of the backbones in the lumbar region. By inserting a needle through your back we can position it to give an injection to block these nerves to one or other leg.
We perform two types of lumbar sympathetic blocks. The needle insertion is the same for both, but we can give either local anaesthetic to numb the nerves for a few hours or a solution, which damages the nerves and blocks their effect for 1 or 2 years.
The choice of injection depends on your condition. We tend to use long acting blocks in circulatory problems. We use local anaesthetic blocks initially in regional pain syndromes; although we may go on to perform a long acting block. Temporary blocks tend to be associated with fewer side effects.
We use lumbar sympathetic blocks for pain and circulatory problems in the legs that we suspect are being made worse by the working of the sympathetic nerves.
The two main conditions we use lumbar sympathetic blockade in are:
We have outlined the use in both conditions below; your consultant will have marked the one relevant to your condition in your hospital notes.
Patients with peripheral vascular disease, which is not suitable for surgical treatment and who have pain at rest or are developing ischaemia (inadequate blood supply) or gangrene (death of tissue as a result of inadequate blood supply) in the foot can often be helped by lumbar sympathetic block.
Blockade of the lumbar sympathetic nerves can lead to a dilation of the arteries supplying the leg on the same side of the body and thus improve the circulation.
If you have rest pain the block may also reduce your pain but our main aim is to reduce the risk of you needing to undergo an amputation. We will give an injection to the nerves that will work for one or two years and therefore help your circulation for a long time.
This is a term to describe a variety of pain conditions, which affect only one part of the body. The pain is often severe and can be associated with discolouration and swelling.
Conditions we would use lumbar sympathetic blockade in include reflex sympathetic dystrophy (also called Sudeks Atrophy Algodystrophy), post amputation pain including phantom limb pain and post herpetic neuralgia (pain after shingles).
In these conditions we would normally use a course of blocks with local anaesthetic that are temporary, and only occasionally use a long acting block after assessing your response to the temporary ones.
You will attend the x-ray department at the hospital as a day case patient. The block will be performed with you lying on your front and awake. It is important you are awake as this reduces the risk of damage to other nerves (see side effects). You will be given a local anaesthetic before the needle is inserted. An X-ray machine will be used to help the doctor position the needle correctly over the nerves.
Following the injection you will be transferred to a ward for bed rest for three to four hours. The injection can sometimes upset your blood pressure and the nurses will monitor this.
The main side effect is a fall in blood pressure, which occurs soon after the injection and is temporary. You may feel that your foot becomes warm on the side of the body you have had the injection.
With a long acting block there is a chance that you will develop 'postural hypotension'. This is a tendency to have dizzy or fainting episodes when you stand up quickly. This can last for about 2 weeks and you should be careful not to stand up and walk too soon after lying down.
There is a small chance of damage to the nerves supplying sensation to the legs. This affects about two to five per cent of patients and can be temporary or permanent. This can cause pain, usually at the top of the thigh. It is more common when we use an injection to give a permanent block. It is less likely to happen when a patient is awake for the injection. Rarely, nerves that are involved with movement may be affected. If the block (permanent) is performed on both sides there is a small risk of ejaculatory failure in men.
There is a very small risk of damage to the bowel or one of the blood vessels in the abdomen. This is extremely rare but can very occasionally require an operation to treat.
These risks are all more common in patients having a long acting block rather than in those undergoing a temporary block with local anaesthetic.
We advise you not to have anything to eat or drink on the morning of the procedure. If this is a significant problem please contact the pain team before your admission so we can advise you and make the necessary arrangements.
The stellate ganglion is a group of nerve cells found on the front of the cervical vertebrae in the neck. It is part of the sympathetic nervous system and controls functions like skin temperature, sweating, heart rate and blood flow in the face, arm and chest.
It is believed that certain pain conditions in the face, arm and chest are due to the sympathetic nervous system malfunctioning. In these cases, switching off this part of the nervous system, even temporarily, can allow the nerves to reset themselves towards a more normal function, thus reducing the pain state.
This block can be very simply performed, usually as a day case procedure. It involves an injection in the front of your neck, just below and to the side of the Adams Apple. In general it only takes 20 or 30 seconds to do and you don't need to undergo sedation or a general anaesthetic. In the vast majority of cases local anaesthetic is used and the direct effects of the block will only last up to six hours. The analgesic effect, however, often lasts considerably longer.
To maximise the analgesic effects of these blocks, several blocks may need to be given over a month or so. Unfortunately, not all patients' pain will respond to these injections.
The immediate effects of a stellate ganglion block can include a hoarse voice, drooping of the eyelid on the same side as the block, the pupil of the eye may go smaller and you may get a stuffy feeling in your nose. This lasts only a few hours and is due to the action of the local anaesthetic.
Often your face and arm may look flushed and feel warm. Some people also notice some numbness on the outer aspect of the arm. Again this is on the same side as the block and lasts only a few hours.
You may have some bruising in your neck for several days after the block and occasionally a sore throat. Very rarely the local anaesthetic will get into one of the blood vessels that supply the head. You may become light-headed and in effect have the equivalent of general anaesthetic and lose consciousness.
Again, very rarely, the local anaesthetic can get into the fluid that lines your spinal cord. Your arms and chest will become anaesthetised and again you may lose consciousness.
Both of these very rare complications are temporary, lasting several minutes to a few hours but mean that these blocks can only be performed in hospital with anaesthetic doctors and nurses available to treat the loss of consciousness safely and appropriately.
It is strongly recommended not to drive, operate machinery or do other activities that require your utmost concentration on the day of the block.
Otherwise, you should carry on with your normal activities, try to increase the physiotherapy exercises you have been given and reduce your painkillers if appropriate.
You will usually be reviewed in the pain clinic after your block.
The majority of vertebrae in your back are connected to one another by large discs and by facets. These facets form a joint. Like most other joints in your body they are designed to move (articulate) in specific ways. They are also very stable joints and quite strong.
Some people can develop pain in their back or neck that is due to aches, sprains, stresses, arthritis or damage to these joints. It is possible to inject a mixture of local anaesthetic and steroid into or near these joints to try and obtain pain relief. This is very similar to injections used for painful knees and tennis elbow.
Pain relief gained will allow you to increase your daily activities, increase your ability to undergo physiotherapy and so strengthen your back and also allow you to reduce your pain killing medication.
The exact location of each facet joint cannot always be determined by clinical examination. Consequently, these injections are performed using constant X-ray imaging (screening) and cannot be done in the outpatient clinic.
The entire procedure is done under local anaesthetic as a day case so you don't need to undergo a general anaesthetic.
Lying on your front, your back is cleaned with antiseptic and the positions for injections are located using the X-ray machine. The skin is then numbed with local anaesthetic. Once this has taken effect the facet joints are injected with the steroid/local anaesthetic solution, again using the X-ray machine for guidance. Usually several joints are injected at any one time.
Facet joint injections can take up to two weeks to provide pain relief. The amount of pain relief gained varies between individuals and even in the same person at different times. Unfortunately, some people get no benefit from these injections.
The duration of effect is also variable. Some people only get few weeks benefit, others many months. However any relief gained will be increased if you are more active during this period.
Do not drive on the day of the injections, or operate machinery/do anything that needs your full, undivided attention. Do not make any important decisions on the day of the injection.
Someone should take you to and from hospital otherwise you can carry out your normal activities as best you can.
Because the injections take a period of time to become effective you may experience some increase in back pain/neck pain for a day or so. There may be some local bruising and tenderness on your skin.
Some people can feel flushed and warm for several days after the injection.
Your pain may be coming from the facet joints, the small weight bearing joints located in pairs all along the spine. This procedure will help by blocking the nerves supplying these joints and reduce the pain. It is performed most commonly, for back / leg pains, but can also be used for inflammation and pain coming from the other nerves. The injection helps to reduce pain, improve mobility, facilitate physiotherapy and thus improve your general functioning. By achieving a reduction in pain we hope that you will take the opportunity to regularly perform back strengthening exercises which is the best way to improve the function of your back over the longer term.
You will be asked to come to the hospital. A cannula (plastic tube) is placed in the back of the hand for medication if required. The injection will be done with you lying on your front. With the help of an X-Ray machine, the correct site is marked on the skin and local anaesthetic (medication that numbs the nerves) is given to numb the skin. The X ray machine is used to ensure accurate placement of the radio frequency needle. In addition the nerves are electrically stimulated with the needle to confirm correct placement. The doctor will ask you what you can feel several times throughout the procedure. After the correct nerves are identified, local anaesthetic is given to numb the nerves before they are deactivated. Deactivation of the nerves may be combined with facet joint injections with local anaesthetic and steroids.
The Radio Frequency nerve ablation/facet joint injections are helpful in some people with chronic backache due to facet joint pain. The pain relief may take days or weeks to take effect and may not be 100% complete. Some patients may not get any relief at all. The effectiveness of the block is difficult to predict. In some groups of patients the injection helps by reducing the number of painkillers that are required to control the pain.
Typically there is some injection site pain and bruising after the procedure and you may initially experience some increase in your pain. It is usually self limiting and easily controllable with painkillers. Some patients may complain of slight numbness of the skin overlying the injection site. This is also self limiting. Very Rarely you may experience some numbness or weakness in a lower limb.
There are very few side effects associated with single or occasional use of steroid injections. Hot flushes, feeling sick or having mild abdominal pain are sometimes felt. Control of diabetes may be difficult, and menstrual irregularities may occur. These settle in a few days. Repeated and frequent use has the potential to lead to more serious side effects, but it must be kept in mind that the dose used in the injection is very small compared to those taking steroids by mouth on a daily basis for conditions such as asthma or arthritis. Regular use can lead to increased appetite, weight gain, thinning of the bones (osteoporosis), thinning of the skin, eye problems (glaucoma, cataract), weakness, depression, rounded face, high blood pressure and water retention have been seen. Oral Contraceptive pills may increase the level of steroids in the blood.
You will be required to stay in the hospital for at least 2-3 hours after the procedure.
If there is excessive or persisting numbness, you may be required to stay in hospital overnight.
A follow up appointment will be arranged, so that the doctor / nurse can review the effects of the block.
You should carry on with your normal activities, try to increase your activity and aim to reduce your painkillers if the effect of the injection appears to have been successful.
A Guanethidine Block is used to treat pain conditions that are confined to a limb. It is a way of temporarily blocking the nerves, and especially the sympathetic nerves, to the affected limb.
The sympathetic nerves are nerves that control automatic functions of the body, and particularly the constriction of the blood vessels, which we see when we get cold. The sympathetic nerves can be involved in maintaining a pain condition affecting the limb. This is especially the case with conditions called complex regional pain syndromes, which include Sudek's atrophy, algodystrophy and reflex sympathetic dystrophy (RSD).
When a regional block is performed it means that the part of the body being treated is isolated from the rest of the circulation. This is done with a tourniquet, which is a tight cuff that is blown-up to a sufficient pressure to cut off the circulation. Use of a tourniquet is safe for up to two hours and is only needed for 20 minutes in a guanethidine block.
Guanethidine is a drug, which has a specific effect on the sympathetic nerves and is normally used to control blood pressure. Although not designed for this use (licence), it has been used for many years by doctors to treat chronic pain. The use of guanethidine is recognised by the international societies for pain management and there are few reported risks to this use.
You will be admitted to one of the wards. A drip needle is inserted into the foot or hand of the limb that has pain. A second drip needle is inserted into the back of the other hand: we may also attach some monitors.
The tourniquet is wrapped around the thigh or upper arm of the affected limb and the limb is elevated for a few minutes to empty the veins. The tourniquet is then blown up to a high pressure, which may be painful for a few minutes.
A mixture of guanethidine and local anaesthetic is then injected through the drip needle into your painful limb. The arm will become numb and you may notice that it is white and blotchy. This is expected and only temporary.
You will then be left to rest for 20 minutes while the drug spreads to the tissues of the arm. The tourniquet will then be let down and your arm may feel warm and tingly.
We will keep you on the ward for about 30 minutes to one hour after the block and will monitor your blood pressure. You will then be free to go home.
You may have to re-attend for further blocks.
As the blocks seldom work as a single treatment we may also ask the physiotherapists to work on increasing exercises for the limb after you have had a block.
Guanethidine blocks are very safe. Like any other drug, patients can have an allergic reaction to guanethidine, which would not occur until after the tourniquet was removed.
There is a very small risk of the tourniquet failing to work properly which may lead to the patient having a blackout. We will keep a close eye on you to ensure the tourniquet is working properly.
We use guanethidine blocks in patients who have previously responded to them. We also use them in patients with regional pain problems, as they are easier to carry out than other sympathetic nerve blocking procedures and have fewer side effects.
There has been debate between pain doctors in recent years about how effective guanethidine blocks are as a treatment. Some doctors argue that they are no more effective than a placebo (pretend) treatment. Others argue that they are a safe and effective treatment. We will continue to look at the available research but are currently happy to continue to use guanethidine regional blocks as we feel they are effective.
If you have any problems or queries about your treatment or its effects please contact the pain team. Alternatively you can speak to your GP.
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