Aided by the CT scanner at Brighton Radiology, particular types of injections are used for people who have chronic spinal pain or sciatica, or those suffering muscle, tendon, joint and painful scar problems.
Conducted by Dr Victor Wilk, the Medical Director of Brighton Spine & Sports Clinic, effective injection therapy is often used when rest, medications and other therapies have not been successful. The therapy is rarely an instant cure, but it can assist in recovery in conjunction with other modalities.
Depending on your issue, injection therapy can include steroid injections (for example for chronic spinal pain and sciatica) and regenerative injection techniques – dextrose prolotherapy, platelet rich plasma (PRP) injections for issues with muscles, tendons, joints and scars.
Some Injection procedures include:
- Transforaminal Epidural:
Transforaminal epidural injections are similar to nerve root (sleeve) injections or nerve root blocks. With transforaminal epidural injections, dye is used to confirm needle placement and the injected material is aimed more at the area of inflammation inside the spinal canal. Whereas, in the case of a nerve root block there is just numbing of the nerve.
The major indication for epidural injections is sciatica or severe shooting leg pains due to a large disc herniation or irritation of the nerve roots in the spine. The pain is typically a shooting or electric shock-like pain down the leg, sometimes burning in quality, associated with pins and needles. Epidurals are also occasionally used for other types of pain in the buttocks or leg, where there is thought to be nerve irritation, but in general epidural injections are not effective for localised back pain.
The precise injection typically takes about 10 to 20 minutes. The patient lies face down over a number of pillows on the table. The skin of the back is sterilised with a cold alcohol based solution. A small needle is placed in the lower back under CT guidance. Once in position, a small amount of dye is injected to confirm the flow of fluid into the spinal canal. Local anaesthetic and cortisone is then injected.
The anaesthetic may cause some tingling and a numb feeling in the affected leg / toes for up to 1-2 hours. The patient may feel weak and unsteady for up to an hour afterwards also, and for this reason it is advisable to have another person drive home. Generally speaking the patient should go home, lie down and take it easy for the day. The next day they can resume light activity including return to light work. It usually takes 7-10 days for the full effects of the injection to work.
- Interlaminar Epidural:
In cases of spinal canal stenosis or disc prolapse where it is not possible to perform a transforaminal epidural, the interlaminar approach may be used. Initially a CT scan is performed to plan the injection procedure and then a needle is directed from the back into the spinal canal. Air is injected first into the canal to confirm correct placement of the injection prior to medicine being injected. At this practice, only non-particulate steroid (dexamethasone) is used for injections into the spinal canal to maximise safety.
- Facet Joint:
The facet joints are the small joints at the back of the spine. They control the movement of the spine. They are generally non-weight-bearing joints, but in heavier people the lower facet joints of the lumbar spine do become weight-bearing and this can add to pain.
It has been shown in studies that the facet joints in the neck are commonly injured in motor vehicle accidents, and account for around 50% of people with ongoing neck pain and headaches post accident. In the lower back, facet joint pain accounts for about 15% of chronic back problems in young people, and around 40% in older adults.
The only way to determine whether the facet joints are the cause of pain is to either inject the joint with local anaesthetic or block the nerves that supply the joint and see if this eliminates the pain. The nerve supply to the facet joints is via the medial branches of the dorsal rami nerves. The injections that are used to determine whether or not the facet joints are painful are called medial branch blocks. To block the pain from one facet joint we need to numb the nerve above and the nerve below the joint in question.
Under CT guidance, the injection itself consists of placing a needle through the skin down to the bone, next to the path of the nerve. A tiny amount of dye is injected and a picture taken to confirm the correct positioning of the needle before local anaesthetic is injected.
Upper neck injections (3rd Occipital nerve block, C3 and C4 medial branch blocks) may result in dizziness and unsteadiness for up to 6 hours afterwards and thus it is highly recommended that you be driven home after the procedure, but for injections elsewhere in the spine there are less after-effects. Repeat confirmatory injections are performed one to two weeks later if the first injections successfully block the pain. If there is no relief then it may be that other levels in the spine may need to be injected and this should be discussed at your next visit with your health care practitioner. For injections into the facet joints, cortisone is often used to provide several weeks relief of pain and stiffness allowing more effective exercise and rehabilitation.
- Sacro-iliac Joint
The sacroiliac joints are large ear shaped joints at the base of the spine that connect the sacrum of the spine to the ilium of the pelvis. Their primary function is to transmit forces from the legs up through the pelvis into the spine and thus are involved in standing, walking and running. The joints are held in place by very strong ligaments including the strong dorsal ligaments. Pain in the area may be due to inflammation within the joints (such as Ankylosing Spondylitis) or from strain to the dorsal ligaments as in the case of pelvic instability. Injections may consist of cortisone to reduce the pain of inflammation or dextrose prolotherapy to help strenghten the weak painful ligaments.
Like the other injections above, the patient lies face down over some pillows for comfort, a scan is taken to plan the injection and the skin sterilised first. Dye is again used to confirm the placement of the needle and the medicine then injected. There is no need to specifically rest afterwards, but it is recommended to take it easy for that day. Patients are asked to complete a pain diary over the next 2 weeks to document any benefit.
- Costovertebral Joint
The costovertebral joints are small joints that connect the ribs to the spine. They may be strained with twisting or lifting injuries or in trauma such as motor vehicle accidents. CT guidance is used to place the needle into the joint. Cortisone may provide several weeks relief of pain to allow more effective rehabilitation. It is again recommended to keep a pain diary following the injection.
- Coccyx Injections
Coccygeal injections are given to treat pain around the tail bone in the lower back. There are several types of injections that can be performed around the coccyx. CT guidance is required for an injection into one of the lower coccyx joints or into the Ganglion Impar which is a nerve plexus just deep to the coccygeal joints. If you are female, please ensure there is no risk of you being pregnant on the day of your procedure. Please contact us if you have any concerns.
- Hip Joint
The hip joints are a common source of groin or buttock pain often related to osteoarthritis. CT guidance may be required to confirm needle placement into the joint. Pains around the hip joints sometimes may overlap other local pain from the buttock muscles or referred pain from the lower back. A diagnostic injection into the joint under CT guidance may be useful in these instances. In the case of more established pain, Cortisone may provide good short term relief of pain; or dextrose prolotherapy or platelet rich plasma injections for longer term benefit to avoid the need for hip replacement surgery.
Contact Brighton Radiology to find out more about CT guided injection therapy.