Treatments

Pain Medicine / Medication Management

Pain Medicine & Medication Management

Definition
Prescription medicines are used regularly in pain management. Although these drugs can be incredibly effective at reducing inflammation and other pain-related symptoms, there is a risk of dependency. Developing a medication tolerance is another serious health threat that can lead to increased medication dosages and more frequent medication use. At TriState Pain Institute, we believe alternative and interventional therapies can help diminish the need for controlled medications while still providing significant pain relief.

Still, the team understands pain medicine is an integral part of pain management. At TriState Pain Institute, prescription pain medicines are monitored closely, and the team works with patients to provide the following:

Diagnostic and therapeutic pain consultations
Compliance and validation of pain medication use
Continual assessment of pain medication efficacy
Monitoring and management of pharmacologic co-morbidities and side effects

On-Site Neurosurgical Care (Brain, Spine, Peripheral Nerve)

Autonomic Nervous System Screening

Definition
The autonomic nervous system (ANS) controls involuntary, physiological actions such as blood pressure, heart rate, metabolism, digestion, and more. When damaged or altered by a disorder, the ANS may produce a number of symptoms like heat intolerance, nausea, constipation, and urinary retention or incontinence. To determine whether or not the physiologic responses of the ANS have been compromised, a TriState Pain Institute physician may administer a series of tests to evaluate the system's level of functioning.

The quantitative sudomotor axon reflex test [QSART], thermoregulatory sweat test [TST], and silastic sweat imprint test are just a few diagnostic tools used during the ANS screening at TriState Pain Institute. Depending on your health history, current health status, and symptoms, you may be required to undergo additional testing.

Purpose of ANS Screening
ANS screening may be deemed medically necessary for patients showing symptoms of vasomotor instability. This is common in patients with different types of neuropathy such as:

Diabetic neuropathy
Amyloid neuropathy
Sjogern's syndrome
Idiopathic neuropathy
Pure autonomic failure
Multiple system dystrophy

Although ANS screening helps identify dysfunctions of the nervous system, it is not a test capable of diagnosing a specific disease. Talk to a TriState Pain Institute physician about ANS screening for signs of disturbances within the autonomic nervous system.

NEUROSURGICAL OPINIONS FOR DIAGNOSIS AND MANAGEMENT

As a board certified neurosurgeon, Dr. Benjamin H. Venger of TriState Pain Institute provides neurosurgical opinions for patients suffering from nerve and spine-related pain conditions. He understands patients often wait weeks or months for neurosurgical consultations from physicians located in surrounding areas such as Las Vegas, Southern California, Phoenix or Flagstaff. In an effort to provide patients with a quality continuum of care, Dr. Venger is available to answer questions about conditions, treatments, recovery, and outcomes related to neurosurgical diseases and disorders.

Post-Operative Neurosurgical Care

Candidates for neurosurgery are generally referred to providers at the Khavkin Clinic in Las Vegas. Following a neurosurgical procedure, patients can receive their post-operative care from the team at TriState Pain Institute. Dr. Venger can perform all of the necessary outpatient provider care services following neurosurgery or spine surgery, creating a comprehensive scope of service and effective time management for patients.

Small Fiber Peripheral Nerve Biopsies for Neuropathy

Definition
The peripheral nerves come from the peripheral nervous system. These nerves read signals from the brain and spinal cord so we can move and feel sensations throughout the rest of the body. Small fiber neuropathy is a condition that results from nerve damage. A tingling or shooting pain often originates in a hand or foot and spreads to the rest of the body. Since these nerves control what we feel, how we breathe, and our perspiration, patients suffering from small fiber neuropathy may have a hard time breathing, sensitivity when touching objects, and experience an impaired sweat response.

What to Expect
In order to treat the condition, physicians must first test to see if the pain is due to small fiber neuropathy. TriState Pain Institute physicians can do this by performing a skin biopsy. Patients will lie on their side as physicians draw five circles about one inch in diameter. They will go on the upper arm, wrist area, upper thigh, lower leg, and the foot. Then, the physician will use a disinfecting agent to clean the area and inject each site with anesthetic. Once they feel numb, the physician will cut a small circle into the skin and remove it from each area. Even though it is small, there are actually nerves living just under the skin that the physician will collect. Overall, patients should not expect the procedure to take more than 30 minutes.

After the Procedure
After the skin samples are collected, the area will be cleaned and dressed with a bandage. We advise patients against driving home after the procedure, but they are able to return home shortly after the procedure. Patients might experience localized pain once the anesthesia wears off. However, since the area of skin removed is small, it should heal quickly.

The sample will be sent to a lab for testing to evaluate whether the nerves have sustained any damage or disease. The lab will send TriState Pain Institute physicians the results in about one to two weeks. If the lab says the diagnosis is confirmed, we can move forward and start to talk about treatment options.

Pain Injections / Interventions: Fluoroscopic and Ultrasonic Guidance (When Appropriate)

Brachial Plexus Block

Definition

The brachial plexus is a group of nerves that extend from the spine to the shoulders, arms, and hands. Damage to the brachial plexus often comes from injuring the shoulder, but it could also be because of inflammation from an underlying condition around the nerves. Patients may feel a tingling feeling going down their arm and may experience weakness. In severe cases, patients may feel pain as well. This is because the nerves are damaged, stretched, or compressed and are sending different signals to the brain.

A brachial plexus block can be used diagnostically. This means that if the patient feels relief after a brachial plexus block, physicians can conclusively determine that the source of the pain is coming from the brachial plexus area.

Additionally, physicians may perform brachial plexus blocks to prepare patients for surgery. The injection acts as an anesthetic that prevents the nerves from being active and firing signals to the brain.

What to Expect
There are several different ways physicians can perform a brachial plexus block, but the different techniques only vary based what approach the physician takes. For example, during an interscalene approach, blocks are injected into the neck while an axillary block goes into the underside of the upper arm. The anesthesiologist will determine the best approach for your procedure. He or she will cleanse the area and administer an injection to make you numb. Then, the anesthesiologist administers the brachial plexus block. Patients do not normally feel pain during the block because the numbness prevents patients from feeling the needle go in, although they may feel a pushing sensation instead.

After Your Procedure
Patients should not expect to feel a lot of pain after the procedure because anesthetic is used prior to the nerve block. Once the anesthetic wears off, the arm may feel a little sore or numb, but this should wear off within a few days. We recommend taking over the counter pain medication if patients are uncomfortable, but the physician may prescribe a higher dose pain medicine following the surgery for excessive pain.

Caudal Steroid Injection

Definition

A caudal steroid injection is a tool physicians use to help treat lower back pain. It can help patients with a wide range of conditions including degenerative disc disease, herniated discs, sciatica, and other conditions stemming from the caudal canal in the lower spine. It works by injecting soothing pain medication directly into the epidural spine (low back area). This bathes the damaged or pinched nerves in medication, helping them feel less irritated.

What to Expect

Patients should not expect a caudal steroid injection to take very long. In fact, it should only take about 15-40 minutes total, and patients can go home the same day. While lying on his or her stomach, patients will be given an anesthetic so they feel a localized numbing sensation on the lower back and will have less pain during the procedure. The physician will use an X-ray machine called a fluoroscope to get a clear view of the needle and the anatomy of the spine. A special dye that shows up on an X-ray is injected into the spine to light up where the caudal steroid injection needs to go. Then the physician mixes anesthetic with the steroid medication and injects it into the area.

After Your Procedure

Patients are advised not to drive or be physically active immediately after the injection. The effects of a caudal steroid injection are very rapid; patients often can feel pain relief from about the time they get home after leaving our office, although some patients may start to feel the effects of the injection the next day. Your physician may want to schedule a follow-up appointment to determine if a repeat injection would be needed in the following months. The procedure has proven to be very safe. Patients should not expect any complications after their procedure, although rare side effects include water retention, soreness, feeling of warmth, and possibly other side effects. The side effects are minor and should subside in a few days, but if they persist, give your physician a call.

Celiac Plexus Block

Definition
The celiac plexus is located in the abdomen around the aorta artery. Damaged nerves in this area can send pain signals to the brain through the spinal cord. This procedure blocks the nerves from sending these signals so patients can hopefully get relief from their stomach pain. Our physicians typically recommend celiac plexus blocks for people who have chronic stomach pain due to injury or an illness such as pancreatitis, Crohn's disease, or even cancer. We also recommend this procedure to patients who have uncomfortable side effects when taking medication for their abdominal condition.

What to Expect
Even though the procedure helps stomach pain, it is not actually done through the stomach. The quick procedure is done with the patient lying on his or her stomach in order to perform an injection to block the nerves from sending pain signals. After the patient is situated, a physician will administer an anesthetic injection to numb the area. Next, a dye is injected into the celiac plexus. The physician uses a fluoroscopic X-ray device to look at the dye and confirm that it is in the correct place. An anesthetic mixed with a pain-relieving steroid injection is then injected. Overall, patients can expect the procedure to last for no more than 40 minutes, although it is often much quicker than that.

After the Procedure
Patients can return home the same day as a celiac plexus block. Patients may feel slightly sore as the anesthesia starts to wear off, but it should not last more than a few days. Physicians cannot determine exactly how long the effects of a celiac plexus block can last as it varies from patient to patient. Some may experience relief for a few weeks while others may have an entire year of reduced abdominal pain. If the nerve block wears off over time, patients can come back to TriState Pain Institute to have the procedure repeated.

Epidural Steroid Injections

Definition
Epidural steroid injections are a minimally invasive treatment option for individuals with pain in the cervical (neck), thoracic (mid-back), and lumbar (low-back) regions of the spine. This injection therapy may also be administered for patients suffering from sciatica. Epidural steroid injections contain an anesthetic and steroid medication to reduce inflammation and pain in the affected regions. Pain relief varies from person to person, but most patients experience relief that lasts anywhere from a few weeks to a few months. Long-lasting pain relief is dependent upon the patient's condition and their response to the treatment.

What To Expect
Similar to other injection therapies, patients must lie face down with their back exposed. A TriState Pain Institute physician will work closely with the patient to identify areas causing pain. Before the procedure, intravenous sedation may be dispensed in conjunction with a local anesthetic to minimize the patient's discomfort. Using a technique called fluoroscopy (x-ray guidance), a hollow needle will be inserted into the injection site and another needle with the medication mixture will be introduced into the epidural space of the spine. As soon as the medication has been administered, the needle will be removed and a bandage may be placed over the injection site.

Post-Procedural Care
Patients may notice a reduction in their pain two or more hours after the treatment. Some pain or discomfort may return shortly after the anesthetic from the injection wears off, but sustained pain relief will likely occur 3-5 days following the procedure. Patients will be advised to rest, minimize their activity levels, and avoid driving for at least 8 hours. A TriState Pain Institute physician will coordinate post-procedural care and a follow-up appointment after the injection.

Facet Joint Injections

Definition
Facet joint injections are a diagnostic and therapeutic tool used to reduce pain and inflammation in damaged facet joints. Patients suffering from spinal conditions such as spinal stenosis, spondylolysis, sciatica, or arthritis typically benefit most from this procedure. When used as a diagnostic test, facet joint injections help physicians determine whether or not a patient's pain is coming from facet joints in the neck or back. If the patient experiences relief following this initial diagnostic procedure, a facet joint injection with a longer lasting corticosteroid will be delivered to the area causing pain.

What To Expect
A review of the patient's medical history and imaging studies will be performed before administering a facet joint injection, which ensures needle placement accuracy. On the day of the procedure, the patient will lie face down on an examination table. A TriState Pain Institute physician will administer conscious sedation to lessen the patient's anxiety and discomfort throughout the procedure, and the skin surrounding the injection site(s) will be numbed with a local anesthetic.

Using a fluoroscope (x-ray device), the physician will insert a hollow needle through the skin, muscles, and sensory nerves of the affected facet joints. A contrast dye may be injected into the facet joint to help locate the targeted joints. Once the needle is in the correct position, an anesthetic and corticosteroid medication will be injected into the facet joint capsule. The needle will then be removed and the injection site may be bandaged.

Post-Procedural Care
Depending on the patient's condition and pain symptoms, more than one injection may be administered to reach adequate pain relief. Patients will be monitored in a recovery room before being allowed to return home. A driver must be present before the patient can be released. Soreness and mild bruising and swelling may occur a few days after the procedure. A TriState Pain Institute physician may request a follow-up appointment 7-10 days after the facet joint injection. Pain relief generally occurs several days after the procedure and may last several days, weeks, or months.

Joint Injection

Definition
Joint injections are a therapeutic treatment option used to mitigate muscle and joint inflammation from degenerative conditions such as arthritis, tendinitis, bursitis, and connective tissue disease. Although short-term inflammation is beneficial for preventing infections and healing injuries, chronic inflammation can cause pain and other complications. Joint injections contain corticosteroids, a class of powerful anti-inflammatory agents that provide long lasting relief to inflamed joints.

What To Expect
Prior to administering the joint (cortisone) injection, a TriState Pain Institute physician will sterilize the skin over the affected joint to reduce the risk of infection. If fluid is present within the joint, a separate, empty syringe will be injected to remove the fluid. This fluid may be sent to a lab for analysis to determine a proper diagnosis. Once the fluid has been removed, the cortisone injection will be administered to reduce inflammation and relieve pain. After the medication has been injected, the needle will be removed and a bandage will be placed over the injection site.

Post-Procedural Care
Patients may be advised to ice the injection site to reduce pain and inflammation. This can be done in 15 minutes intervals, once or twice an hour. Over-the-counter pain relievers can be taken within the first 24 to 48 hours after the procedure. Patients should monitor the injection site for signs of an infection and report any signs of swelling, warmth, fever, or chills to their TriState Pain Institute physician. A follow-up appointment will be scheduled shortly after the procedure. If the initial joint injection is deemed successful, a maximum of four injections can be administered a year.

Lumbar Sympathetic Block

Definition
As the name suggests, the sympathetic nerves are a part of the sympathetic nervous system. The sympathetic nerve chain runs through the entire spine on both sides, so it is possible to have a sympathetic nerve block in the cervical or thoracic spine in addition to the lumbar spine.

A lumbar sympathetic block is generally used as a diagnostic tool. If pain subsides after receiving a lumbar sympathetic block, then the physicians can determine that a patient's back pain is most likely originating from a nerve in the sympathetic nerve chain.

However, it can be used as a form of pain treatment as well. In fact, it can be used to treat pain stemming from conditions such as shingles and other conditions affecting the lumbar spine.

What to Expect
During the procedure, patients can expect to be lying on their stomachs or their side. After the patient is relaxed, the tissues surrounding the sympathetic nerves are numbed via an anesthetic injection. Next, using a fluoroscope, the physician will guide the needle toward the sympathetic nerves. The physician might use a special dye that the fluoroscope can see to confirm that the injection is going into the right place. The dye is not harmful and is not visible on the outside of the skin. Finally, keeping the hollow needle in place, a mixture of an anesthetic and steroid solution is injected.

After the Procedure
Once the procedure is over, we may ask patients to stay in the office for a little while as the anesthesia wears off. Once patients return home, they made experience a few side effects, including numbness in their legs or weakness. Additionally, patients may feel a little tender around the injection site, but the side effects should not last more than a few hours. If the lumbar sympathetic block was used diagnostically, the patient may be asked to return in a few days to monitor the success of the nerve block. If the cause of pain was indeed the sympathetic nerves, our physicians can start treatment as soon as possible.

Occipital Nerve Block

Definition
An occipital nerve block is an injection therapy that helps reduce inflammation and pain around the greater and lesser occipital nerves, which are located on the back of the head just above the neck. When damaged or irritated, the occipital and suboccipital nerves can cause migraines, tension headaches, and occipital neuralgia. Similar to other nerve blocks, an occipital nerve block may contain a local anesthetic and steroid medication to provide pain relief that can last a few days, weeks, or months.

What To Expect
Before the procedure, patients will be asked to lie face down so the injection site can be properly cleaned. A TriState Pain Institute physician will then develop a medication solution for the patient's condition and symptoms by mixing local anesthetics and corticosteroids. Once this medication mixture has been created, it will be injected into various sites along the occipital nerves. Patients may experience a slight burning pain during the initial injections, but this sensation should subside once the numbing agents take effect. Gauze may be applied with manual pressure to reduce the risk of bruising.

Post-Procedural Care
Patients will be required to stay at the clinic for 15-30 minutes following the injection to ensure a stable blood pressure and pulse. A follow-up appointment may also be made during this time. Patients may experience a mild headache and soreness after the procedure, but these symptoms should lessen after 48 to 72 hours. Due to the nature of this procedure, patients will need to be driven home after their occipital nerve block. Normal activities can be resumed once a Tristate Pain Institute physician has approved them.

Peripheral Nerve Blocks

Definition
A peripheral nerve block is a therapeutic injection that interrupts the transmission of pain signals to and from peripheral nerves. The peripheral nervous system is made up of 43 pairs of nerves that control sensation, movement, and coordination. If damaged, these nerves can cause a number of complex, debilitating symptoms including shooting, burning, or throbbing pain in the limbs and throughout the body; muscle paralysis and spasms; reduced coordination and balance; and increased sensitivity to touch. A peripheral nerve block decreases irritation and inflammation of the affected nerves and reduces pain.

What To Expect
The procedure begins with the patient lying face down on a table with his or her back exposed. Patients may be given a mild sedative to minimize discomfort throughout the procedure. Using ultrasound guidance, a TriState Pain Institute physician will identify affected nerves and determine the placement of the peripheral nerve block.

The skin around the injection site will then be numbed with a local anesthetic. Once the anesthesia has taken effect, a hollow needle will be inserted through the skin and into the peripheral nerves where a medication mixture will be injected. For patients requiring a continuous nerve block, a small catheter will be placed into the targeted nerves and will remain in the body for several days. Gauze and a bandage may be placed over the injection site once the medication has been administered.

Post-Procedural Care
Patients may be asked to reduce their normal level of functioning for several hours or days after the procedure. Mild swelling and soreness may be present after the treatment. This is normal and should subside after 2 or 3 days. Patients should monitor the injection site and apply new bandages if necessary. A peripheral nerve block may provide anywhere from several weeks to several months of pain relief, depending on the severity of the patient's condition and symptoms.

Radiofrequency Neurotomy

Definition
Radiofrequency neurotomy, also called radiofrequency ablation, is a minimally invasive procedure that uses radio waves to reduce pain in the cervical, thoracic, and lumbar spine, as well as the foot and shoulder. The radio waves generate heat, which is then used to treat damaged nerves transmitting pain signals to the brain. This procedure may be recommended for patients who've experienced relief from diagnostic injections called nerve blocks. This semi-permanent procedure is performed on an outpatient basis, allowing patients to return home the same day.

What to Expect
Radiofrequency neurotomy begins with the patient lying face down on an operating table. A TriState Pain Institute physician then administers a sedative as well as a local anesthetic to relax the patient and numb the affected area. Using an x-ray guidance device, called a fluoroscope, the physician inserts the radiofrequency needle alongside damaged nerves. A special generator will be used to produce radio waves that heat the tip of the radiofrequency needle. A heat lesion is then created on the nerve, which subsequently impairs its ability to send pain signals to the brain. After the targeted nerves have been treated, the radiofrequency needle will be removed and the operation site will be bandaged.

Post-Procedural Care
Following radiofrequency neurotomy, the patient will be sent to a separate room to recover. Soreness, mild bruising, and swelling may be present near or around the injection site. These symptoms typically dissipate after a few days. Pain relief usually lasts anywhere from six to nine months, but there are instances where symptom relief lasts up to two years.

Sacroiliac Joint Steroid Injection

Definition
The sacroiliac joints, also known as SI joints, are located on the pelvis near to the spine and are located more inward than the hips. In fact, the SI joint is more of a buffer between the hips and spine. When damaged, these joints can cause a lot of pain, discomfort, and immobility in the lumbar spine and legs.

A sacroiliac joint steroid injection can be used for one of two reasons: to diagnose a problem and to ease pain. When used for diagnostic purposes, the injection is used to determine if the pain is coming from the SI joint or another source. If pain persists after the injection, our physicians will continue to look for alternative sources and causes of pain. However, if pain is relieved, physicians can start treatment on the SI joints. In addition, if it is already known that the sacroiliac joints are damaged, we can use a sacroiliac joint steroid injection to treat the pain.

What to Expect
The patient can expect to have the procedure done posteriorly. This means that the physician will have the patient lie on his or her stomach so the injection can go into the lower back. The patient should not expect to feel the needle because the physician will administer a numbing anesthetic. Once the area is numbed and cleaned, the physician will inject a dye into the sacroiliac joint. The dye is used because it shows up on our X-ray device called a fluoroscope. This way, physicians can use the fluoroscope to guide the injection properly into the SI joints. Finally, a solution of anesthetic and steroid medication is injected into the joint, relieving pain.

Overall, patients should expect this procedure to take about 30 minutes, but patients be required to stay longer to wait for the anesthesia to wear off.

After the Procedure
After the injection, patients are asked to refrain from strenuous activity and to consume plenty of water. We do not anticipate many side effects, but patients may feel a little sore around the lower back. Patients should keep the area clean and look for signs of infection and allergic reaction including bleeding, redness, swelling and excessive pain. Patients can expect to feel relief starting between 15 minutes after the procedure to about three days. Pain relief should last several months, but if the effects wear off, the injection can be repeated.

Sciatic Nerve Blocks

Definition
Sciatic nerve blocks are therapeutic injections that provide pain relief to those suffering from sciatica, a chronic pain condition that causes intense shooting pain along the sciatic nerve. When the sciatic nerve becomes damaged or compressed by surrounding muscles or a herniated or bulging disc, pain, tingling, numbness, limping, and muscle weakness may occur. This injection therapy may also be used to provide postoperative pain relief from an amputation or surgical procedure to a limb.

What To Expect
Patients are first given a sedative either orally or intravenously to help reduce discomfort throughout the procedure. Most sciatic nerve blocks are performed using ultrasound guidance to help with needle placement accuracy. The patient will lie on his or her side with the affected area exposed. A TriState Pain institute physician will sanitize the injection site and mark areas of the skin where the needle(s) will be inserted. A hollow needle will be inserted through the skin into the sciatic nerve.

A separate syringe containing an anesthetic and medication solution will be injected into the sciatic nerve. Patients may experience some pressure and a slight burning sensation during the injection, but this should subside after a few seconds. After the medication mixture has been introduced into the affected nerve, the needle will be removed and a bandage will be placed over the injection site.

Post-Procedural Care
Similar to other injections, patients will be placed in a recovery room for 15-30 minutes so they can be monitored for any signs of complication or adverse reactions. A TriState Pain Institute physician may advise patients limit their physical activity levels for at least 48 hours. Patients may feel immediate pain relief shortly after the procedure due to the anesthesia. This may dissipate after a few hours, but long-term pain relief will likely be felt 3-5 days after the injection. Patients should notify their pain management physician of any signs of infection, swelling, spontaneous bleeding, or unusual pain.

Selective Nerve Root Injection

Definition
A selective nerve root injection is a minimally invasive procedure that administers pain medication to a specific nerve root along the spine. There are many openings within the spinal column called foramina that act as doorways for nerve roots to connect to various bones, muscles, and organs throughout the body. Vertebral misalignment or bulging spinal discs can irritate or pinch these surrounding nerve roots, causing pain. For mild herniations, bones spurs, and other complications of the spine, a selective nerve root injection may be recommended to reduce pain and discomfort.

What To Expect
The procedure begins by injecting a local anesthetic into the areas causing pain. Once the injection sites are numb, another needle containing a steroid medication will be injected into the affected nerve roots. Patients may experience some pressure and discomfort during this part of the procedure. The anesthetic within the medication will take effect after 15 seconds, at which point the patient should experience little to no pain. The physician may ask a series of questions regarding the patient's comfort and level of pain to determine whether or not more medication needs to be administered. Once the affected nerve roots have been identified and treated, patients will be bandaged and sent to recover.

Post-Procedural Care
If the patient received IV sedation during the procedure, he or she will have to wait until the anesthesia wears off before driving home. A TriState Pain Institute physician may recommend coordinating transportation with a friend or family member to avoid waiting for a long period of time. Patients should avoid strenuous activities for the first 24-48 hours after treatment.

Stellate Ganglion Block

Definition
The stellate ganglion is a member of the sympathetic nervous system and is located on both sides of the neck. If damaged, it can cause pain in the head and neck area as well as the arms. If pain in any of these regions persists, a physician may recommend a stellate ganglion block. It is a diagnostic tool that, if successful, lets a physician know that the source of the pain is coming from the stellate ganglion region. If the nerve block does not adequately treat pain, then the stellate ganglion can be ruled out.

What to Expect
Patients can expect to have the injection towards the front of the neck. The block will be at the base of the neck closer to the collarbone rather than near the chin. During the procedure, the patient will be lying down. Patients first receive local anesthesia to make the area numb. If the physician chooses to use a fluoroscope, a dye will be injected to confirm that the needle is going directly into the stellate ganglion. Finally, anesthetic medication is injected through the needle. Coughing or swallowing may move the needle, so patients may be asked to reschedule if they become sick.

Patients can expect to stay in the office for a short time as the physician monitors the patient for an allergic reaction, but the entire procedure should not last more than an hour.

After the Procedure
Our physicians advise against driving home after a stellate ganglion block because the anesthesia may still be impairing the patient. Patients may experience a few side effects as the anesthesia wears off, including: drooping of the eyelids, numbness around the arms and neck, temporary hoarseness, or feeling warm. Patients may have an allergic reaction to either the dye or the solution once they get home, so patients should look out for shortness of breath or swelling. If these symptoms arise, please call our office immediately.

Suboccipital Nerve Block

Definition
A suboccipital nerve block is an injection procedure that reduces pain within the four suboccipital muscles located along the back of the neck and at the base of the skull. Frequent movements and damage to the occipital and suboccipital nerves can lead to a number of pain symptoms and conditions such as tension headaches, occipital neuralgia, and temporomandibular joint dysfunction (TMJ). Much like other nerve blocks, suboccipital nerve blocks contain a local anesthetic and steroid medication that can be administered for diagnostic or therapeutic reasons.

What To Expect
Patients must lie face down to provide the TriState Pain Institute physician with easy access to the injection site. As soon as the targeted area has been properly sanitized, a medication solution containing local anesthetics and corticosteroids will be created and injected into the suboccipital nerves. This area typically includes the back of the neck and base of the skull. A slight burning pain may be felt during the injections, but this feeling should diminish after a few seconds when the anesthetic has taken effect. A bandage may be applied following the procedure.

Post-Procedural Care
Shortly after the procedure, patients will be taken into a room to recover. Unless there are complications, patients will be able to return home that same day. Soreness around the injection site and a mild headache may be felt a few hours after the nerve block. The steroid may take 3-4 days to take affect. Most patients will experience pain relief that lasts several days to a few months. A TriState Pain Institute physician will explain postprocedural care instructions with you and schedule a follow-up appointment. Patients will need to rest several hours after the procedure and avoid driving or operating heavy machinery for 12-24 hours post-op.

Sympathetic Blocks

Definition
A sympathetic block targets the nerves in the sympathetic nervous system and is used as a treatment for chronic pain. These nerves live in your spinal cord and brain and regulate bodily functions such as digestion, sweating, and more notably, the "fight or flight" response. Since the sympathetic nerves are in the spine, this type of nerve block will be injected into the spine as well. The area of pain helps determine where in the spine the injection should go. For example, if a patient is suffering from complex regional pain syndrome and feels pain in their feet, a lumbar (lower spine) sympathetic block would likely be the most useful.

A sympathetic nerve block can also be used as a diagnostic tool. This means that if the sympathetic nerves are blocked during this procedure and the patient finds pain relief, then the physician will know that there is a problem within the sympathetic nervous system. Additionally, it can be used to treat pain. A sympathetic nerve block disrupts nerves from sending pain signals.

What to Expect
Before coming into TriState Pain for a sympathetic nerve block, patients may be asked to fast the night before the procedure and avoid blood-thinning medications. The day of the procedure, patients can expect to lie on their backs. After the area is injected with local anesthesia, the physician will begin the procedure. Using an X-ray device, they will guide a needle into the side of the spine. The physician may put a special dye into the needle and down into the spine to confirm that the needle is in the right position. Finally, the physician will inject a steroid medication into the needle. This soaks the nerves in medication and soothes them.

After the Procedure
After the procedure, patients are bandaged and asked to stay for a short while. This way, a physician can screen the patient and look for any signs of infection or allergic reaction. Patients may experience numbness or weakness in their limbs after the procedure. This is a normal occurrence and should subside soon. A sympathetic block is not a long-term solution to chronic pain, and patients can have the procedure repeated a few times throughout the year.

Transforaminal Epidural Steroid Injections

Definition
Transforaminal epidural steroid injections provide relief to damaged or irritated nerve roots within the cervical, thoracic, and lumbar spine. This minimally invasive, outpatient procedure is typically administered to those experiencing back pain from degenerative conditions such as spinal stenosis or radiculopathy. The injection contains a steroid-anesthetic medication, and it usually takes a few minutes to complete.

What to Expect
The procedure will begin with the patient lying face down on an examination table with a cushion placed under his or her abdomen. This helps keep the patient comfortable and provides easy access to the foramina (spaces on either side of the spine) for the injection.

The targeted area will then be cleaned, and a local anesthetic will be administered to reduce pain during the procedure. Using an x-ray device called a fluoroscope, a contrast dye will be injected into the foraminal space surrounding the irritated nerve roots. This helps TriState Pain Institute physicians identify the correct position for the steroid-anesthetic medication. Once the correct location has been confirmed, the medication will be injected into the irritated nerve roots. The needle will then be removed, and a bandage will be placed over the injection site.

Post-Procedural Care
Multiple injections may be needed to provide sufficient pain relief. Patients should feel immediate pain relief following the injection. This is largely due to the anesthetic, which is why patients may also experience pain a few hours after the procedure. Long lasting pain relief from the steroid medication is usually within 3-5 days. Patients should rest, limit their activity levels, and report any swelling, redness, rash, or unusual pain to their TriState Pain Institute physician.

Trigger Point Injections

Definition
A trigger point injection is an outpatient procedure that reduces myofascial pain caused by trigger points, which are characterized as small, knotted muscles. These tender nodules are typically located within the fascia tissue of the back, neck, and shoulders. Trigger point injections can be used to treat trigger points and chronic inflammatory pain conditions such as fibromyalgia, temporomandibular joint dysfunction, and tension headaches. These injections typically contain a mixture of anesthetics and corticosteroids, but they may also contain no medication solution at all. When no medication is used, the technique is called dry needling.

What To Expect
Before the procedure, a TriState Pain institute physician will ask the patient to either lie face down or remain seated to prepare for the injection. Once the patient is positioned comfortably, the physician will manipulate the skin to locate the trigger points. These palpable nodules are relatively easy to find due to their tough anatomy. When the trigger point has been correctly identified, the physician will clean the injection site and carefully insert the needle into the nodule. The medication mixture will be injected and the trigger point will be monitored closely. If the trigger point does not relax or the patient has more than one nodule, additional injections will be administered to provide sustained pain relief.

Post-Procedural Care
Following the treatment, a small bandage may be placed over the injection site(s). A TriState Pain Institute physician will provide the patient with simple stretches and movements to reduce pain, stiffness, and swelling during recovery. Patients may also apply an ice pack to the affected area(s) to decrease discomfort. If complications do not arise immediately after the procedure, patients will be able to return home that same day. A follow-up appointment may be made a few days or weeks after the trigger point injection to observe the treatment's progress.

Vertebroplasty

Definition
Vertebroplasty is a minimally invasive outpatient procedure that repairs painful compression fractures in the spine. Vertebroplasty employs similar techniques as a procedure called kyphoplasty, but kyphoplasty uses a small, inflatable balloon to correct spinal fractures. Both vertebroplasty and kyphoplasty help restore bone height and reduce the risk of spinal deformity from mild to moderate compression fractures. Most spinal fractures are caused by the bone-thinning disease osteoporosis, but they can also develop from a trauma or infection. The pain management specialists at TriState Pain Institute may recommend this procedure to patients with compression fractures that are less than six months old.

What To Expect
An x-ray, complete medical history, and physical examination will be performed before the procedure to determine the precise location of the fractured vertebra. During the procedure, A TriState Pain Institute physician will provide the patient with a sedative to minimize discomfort. For severe cases, general anesthesia may be administered to keep the patient comfortable. An incision will be made above the affected area where a hollow needle will then be inserted. Using x-ray guidance, the physician will inject areas of the vertebrae with cement. With kyphoplasty, a small balloon will be inflated to increase spinal height before cement is injected in the fractures. As soon as the vertebrae have been treated, the needles will be removed and the incision will be closed.

Post-Procedural Care
Patients may need to lie on their back for at least one hour while the cement hardens. After one or two hours of observation, the patient will be able to return home. Swelling, bruising, and mild discomfort may be present following the procedure. A TriState Pain Institute physician will provide the patient with a back brace to aid recovery. Pain relief may be felt either immediately after the procedure or within 72 hours. A follow-up appointment will be scheduled several days or weeks after the procedure.

Alternative (Non-Medication) Therapies

Discography

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Double Discography

Joint Bracing

Definition
Joint bracing is a conservative treatment option for those with acute injuries, chronic joint pain, or carpal tunnel syndrome. Braces and splints can be useful in preventing injury and protecting joints after surgery. A TriState Pain Institute physician may recommend joint bracing for the following reasons:

Improve physical function
Decrease pain
Stabilize an injury
Slow disease progression

Although joint braces and splints do not replace a surgical procedure or rehabilitation program, they can immobilize unstable joints and improve discomfort and function. A physician will explain how to apply the brace and how frequently the brace should be worn, should you require one for treatment.

Custom-Built Orthotics
At TriState Pain Institute, custom-built orthotics may also be recommended for patients suffering from heel spurs, plantar fasciitis, diabetic neuropathy, and other foot-related health problems. Every pair of orthotics is custom-made for the patient's feet and underlying condition. To set patients off on the right foot, an impression will be made and sent to a lab. Once a mold has been made, a TriState Pain Institute physician will perform an examination to ensure the product exceeds expectations.

Medical Food Agents

Medical food agents are FDA-approved nutritional medications that work as essential metabolic agents. The physicians at Tristate Pain Institute may prescribe this therapy to treat obesity, which can be a contributing factor to inflammation and pain, muscle spasms, and joint pain. It works by enhancing the patient’s metabolism and other aspects of the physiological process in order to promote weight loss. The medications are available to patients at our pharmacy with a prescription from your physician.

Metabolic Medicine

Metabolic medicine utilizes an array of medical disciplines to identify and correct metabolic imbalances. Chronic pain is often affected by metabolic entities, which is why Dr. Benjamin H. Venger may analyze the weight, diabetic management, diet, and exercise of patients before administering treatment for chronic pain.

After administering a clinical examination, complex biomarker assessment, and confirmatory diagnostic imaging for metabolic medicine, Dr. Venger works with patients to develop a comprehensive treatment plan to improve the health, longevity, and lifestyle of those affected by metabolic imbalances.

This treatment plan may include a combination of therapeutic modalities, such as nutrition counseling, weekly or monthly weigh-ins, supplements, physical therapy, chiropractic care, and preventative medicine.

Percutaneous Electrical Nerve Stimulation (PENS)

Definition
Percutaneous Electrical Nerve Stimulation (PENS) is a non-medication therapy we use to treat chronic pain, particularly in those suffering from neuropathy. It uses electrical stimulation to change the signals the nerve is sending. Research shows that when stimulated, nerves may decrease the pain signals, which in turn provides pain relief. PENS is often confused with electro-acupuncture because both use thin needles to send electricity down into the needles. However, acupuncture needles are placed based on an ancient Chinese practice in order to best repair the body's energies. Unlike acupuncture, PENS places the needles very near to the nerve and nowhere else on the body.

What to Expect
During the procedure, up to 10 needles are inserted into the skin near the injured nerve after anesthesia has been administered. Then, a low-voltage electrical stimulation is connected to the needles. This allows the electricity to go down the needles and into the tissues surrounding the nerve. Patients should expect treatment to last about 30 minutes, although some patients may receive treatment for up to an hour if necessary.

After the Procedure
After the procedure, patients can return home the same day. If given local anesthesia, patients may be asked to have someone drive them home from our office. Severe side effects such as nerve damage are very rare, but patients may experience slight bruising or soreness after they get home. Since this form of therapy does not require any medication, patients should not experience any side effects generally related to pain medication. If necessary, the procedure can be repeated. Unlike a steroid injection, there is no limit on how many times the procedure can be repeated.

Spinal Bracing

Spinal orthoses are medical devices used to support and stabilize areas of the neck and spine. They may be used to mitigate a degenerative disease, correct a spinal deformity, or promote healing after a surgical procedure. Depending on the patient's condition, spinal braces can be made from a range of materials such as soft, flexible fabrics or hard, rigid plastics. A custom-made orthotic with molded plastic and padding may be recommended for patients who require maximum spine stability, or for those suffering from a spinal condition like scoliosis. TriState Pain Institute offers custom-molded and custom-fit spinal braces.

Topical Creams & Patches

Topical pain relievers are medications that come in various forms, including creams and patches, and they are applied to the skin to administer direct pain relief. These medications are often prescribed to patients who are either uncomfortable with or incapable of taking oral pain relievers. Topical pain relief creams and patches may also be dispensed to patients with pain in a localized area, like a damaged joint or area of skin affected by the shingles virus. These medications often contain a nonsteroidal anti-inflammatory drug to reduce swelling and combat pain. Other topical pain-relieving creams and patches contain narcotics and counter-irritants to not only provide significant pain relief, but to also offer some comfort from the harsh ingredients.

Not everyone is a candidate for topical pain relievers, so it's important to discuss this type of therapy with a TriState Pain Institute physician. Similar to oral pain medications, it is possible to overdose on a topical cream or patch. Talk to a TriState Pain Institute today for more information about this pain management alternative.

Pain and Other Related Services

Complex Biomarker Assessment

A complex biomarker assessment is a blood test that identifies a patient’s genetic predisposition to various health problems and chronic conditions such as atherosclerosis, heart disease, diabetes, and more. Results from the assessment can help determine whether or not a patient is at risk of developing or becoming affected by a chronic pain condition. This blood test will also help physicians understand a patient’s rate of drug metabolism.

Anyone is considered a candidate for this blood test. Insurance coverage for a complex biomarker assessment varies depending on the patient’s health benefits. If testing leads to a diagnosis, patients may be awarded coverage based on the medical necessity.

Disability Examinations

Consultative examinations (CEs), also known as disability examinations, are medical assessments that help determine the extent of a patient’s impairment from a chronic condition or injury. These exams are a contracted service between the examiner and an administrative entity (DES, insurance company, etc.), and they are usually administered to patients applying for Social Security Disability benefits. During a disability examination, a TriState Pain Institute physician reviews the patient’s health records, diagnostic imaging (if applicable), and performs a comprehensive examination following established, published guidelines.

Dr. Benjamin H. Venger of TriState Pain Institute is certified by the American Board of Disability Examiners to conduct disability examinations and provide patients with disability ratings.

Discography (Discogram)

Definition
Discography, also known as a discogram, is a diagnostic procedure that helps physicians identify the cause of back pain. This minimally invasive procedure injects sterile liquid into various spinal discs to induce pain. If the patient reports pain during the procedure, the physician can note the pain's location. Discography may be recommended to patients experiencing mild to moderate back pain who have not responded well to conservative treatment. Once the test is complete, physicians will develop an appropriate treatment regimen.

What To Expect
Before the procedure, the patient will lie face down on a table. An intravenous line with sedatives and other medications will be administered at this time. A local anesthetic may be injected into the various test sites to minimize pain and discomfort. The table will be outfitted with an imaging device to help the physician find damaged spinal discs.
Using a fluoroscope, the physician will insert several needles into spinal discs that may be causing pain. Once the need is in place, a contrast dye will be injected. This will induce pressure or pain in the spinal disc. If the patient reports pain, he or she will be asked to rate it on a pain scale and describe its characteristics. The x-ray imaging device will display how the contrast dye moves within the spinal disc. If it stays localized within the disc, there may be little to no damage present. If the dye spreads outside the spinal disc, physicians can speculate serious damage and act accordingly.

Post-Procedural Care
Shortly after the procedure, patients will be taken into a separate room to recover. A discogram can take up to three hours to complete. Once the physician has accurately identified the source of a patient's pain, he or she will determine the best form of treatment. Other tests, like an MRI or CT scan, may also be administered to help formulate a diagnosis. Patients will be advised to limit physical activity and stop taking certain medications that may hinder the healing process.

Intrathecal Pain Pump

Definition
An intrathecal pain pump is an implanted, programmable device that delivers pain medication to the space surrounding the spinal cord (intrathecal space). This device helps prevent pain signals from being sent to the brain. When a patient is feeling pain, he or she can use an external unit to dispense the appropriate amount of medication to affected areas. Candidates for this procedure generally include patients who have not experienced relief from conservative or interventional pain treatment, and patients who are not considered candidates for spine surgery. An intrathecal pain pump requires medication refills every few months.

What To Expect
Similar to spinal cord stimulation, patients must first go through a trial procedure before a permanent intrathecal pain pump can be implanted. During the permanent procedure, general anesthesia is administered to relax the patient and minimize his or her discomfort. Next, the operation site is thoroughly cleaned and sanitized before a small incision is made into the intrathecal space. A hollow needle will be placed through the incision to help physician place a permanent catheter.

Once the catheter is implanted, the pump is placed under the skin in the abdomen or buttocks. The catheter and pump are then connected so the device can administer the patient's medication successfully. Pumps typically last anywhere from three to five years, so patients will need to undergo additional procedures to replace their pumps. The hollow needle is then removed and the incision is closed.

Post-Procedural Care
Following the procedure, patients are transported to a separate room to recover. Once the patient has received a thorough post-surgical evaluation, he or she will be sent home to continue their recovery. Patients may experience mild swelling, bruising, and itching near the incision site. A TriState Pain Institute physician should examine patients with symptoms that are severe and last for more than several days or weeks. Strenuous activity should be avoided for several weeks.

Medical Marijuana (RE)Certification

Definition and Certification Information
The Arizona Medical Marijuana Act (AMMA) authorizes the legal use and dispensation of medical marijuana in the state of Arizona. The Arizona Department of Health Services (ADHS) enforces the regulations of the AMMA by certifying the legal possession of registry identification cards for qualifying patients.

A TriState Pain Institute physician may recommend medical marijuana for patients with chronic illnesses. As outlined by the ADHS (A.R.S. §36-2801), qualifying patients must have a "debilitating medical condition" certified by their health care provider. Following physician approval, patients must submit a Qualifying Patient Application to the ADHS before medical marijuana can be dispensed.

Qualified patients include adults and individuals under the age of 18. For patients under 18, a parent or legal guardian must be complete an Attestation form when submitting their child's application for a registry identification card.

Renewal Information
The Arizona Medical Marijuana Act requires the renewal of registry identification cards annually. To complete the renewal process, patients must go through a series of steps. For more information regarding the certification or recertification process, call Dr. Benjamin H. Venger at TriState Pain Institute today.

Pharmacologic Genetic Testing

Definition
Pharmacologic genetic testing, also called drug-gene testing, is an assessment that studies how a patient's genetic makeup impacts their body's response to certain medications. At TriState Pain Institute, pharmacologic genetic testing may collect a number of blood or saliva samples to test against various medications. Although numerous samples may be taken initially, a pharmacogenomic test may only need to be administered once because a person's genes never change.

The purpose of this testing is determine the best medication and medication dosage for patients, and to identify medications that may produce serious side effects. Pharmacologic genetic testing is typically recommended on a case-by-case basis. The cost of the test may vary depending on the test that is ordered and if the patient's health insurance provides coverage.

Spinal Cord Stimulation (Trial & Permanent Implant)

Definition
Spinal cord stimulation, also called neuromodulation, is a minimally invasive procedure that uses electrodes to reduce chronic nerve pain. During the procedure, small leads (medical wires) are placed around the area of reported pain, usually in the epidural space above the spinal cord. These leads produce electrical impulses that override pain signals being sent to the brain. Spinal cord stimulation is typically reserved for patients with severe neuropathic pain (i.e. radiculopathy, diabetic or peripheral neuropathy, complex regional pain syndrome (CRPS), etc.) that has not responded to other treatments for at least six months.

What To Expect
Before the permanent device can be implanted, patients must first undergo a trial procedure with a temporary stimulator. This provisional device allows patients to experience spinal cord stimulation. It also helps physicians determine whether or not the permanent device will be successful in relieving pain. During the permanent implantation, patients must lie face down so the surgical site can be properly sanitized for surgery. A TriState Pain Institute physician will administer conscious sedation and a local anesthetic to reduce discomfort throughout the operation.

Once the anesthetic has taken effect, an incision will be made in a predetermined location around the epidural space. A hollow needle is then placed into the incision where small leads will be inserted and implanted. Another small incision will be made for the implantable pulse generator (IPG), which will be positioned underneath the skin either in the buttocks or the abdomen. The incisions will be closed and the patient will be sent to a recovery room.

Post-Procedural Care
Following the permanent implantation, a TriState Pain Institute physician will program the internal IPG with an external wireless programmer. During this time, the patient will be taught how to turn the system on or off, adjust the power, and choose different programs. Swelling and mild discomfort around the surgical site is normal and should dissipate after several days. Patients who develop a fever, rash, or experience increased bleeding should call TriState Pain Institute right away. Because this is an outpatient procedure that requires anesthesia, patients will need to driven home after their surgery. Normal activities can be resumed after several days.

Urine Toxicology Screening & Monitoring

Definition
A toxicology screening examines a patient's urine to evaluate the person's drug use. From the urine, physicians can see which drugs the patient has taken and the dose taken. The drug screen can detect a number of substances including alcohol, marijuana, narcotics, prescription medication, and more. At TriState Pain Institute, we perform the test because it is mandatory compliance for prescription drug use. We want to make sure that the substances our physicians prescribe are used correctly at the right times at the right doses and won't interact with any harmful substances.

What to Expect
Patients may be asked by a TriState Pain Institute nurse to collect a urine sample before they see their physician. Patients will be given a disinfectant wipe and a small cup. Patients will need to wipe their genital area before collecting their sample. The area does not need to be scrubbed; a simple wipe as if you just used the restroom will suffice. Next, patients should fill the cup with their urine. The cup should be filled to the line printed on the side. If patients cannot urinate, they may be asked to drink water until they can or to try again after their appointment concludes. Patients should then deliver their sample and wash their hands thoroughly with soap and water.

After the Screening
Following the urine toxicology screening, patients can proceed to see their physician. Results of the test will come back very quickly, before you leave our office most of the time. If nothing unusual appears on the screening, the patient is free to go home. However, if something other than the prescribed medication and dose appears, patients may be questioned by their physician. Questions may include whether or not a woman is menstruating (if blood appears on the test), questions about diet, and whether or not they have maintained their prescription schedule.

Workman's Compensation Care (Active & Supportive Care)

Definition:

Under Arizona law, when a worker is injured in a job-related incident, their employer can compensate them for their medical care. There are two types of worker’s compensation available. Active care means that a medical professional is working to improve your condition. Most patients fall under this category as it relates to the initial treatments after an injury. However, if patients became permanently disabled after the incident, they may need what is known as supportive care. Supportive care is for patients who are typically unable to work any longer and require continued assistance. This is the case for many people suffering from chronic pain.

The TriState Pain Institute is dedicated to working with patients receiving workman’s compensation care. Our staff will ensure that you are receiving the care you need to get back on your feet again after an injury. We have plenty of experience working with insurance companies and making sure that they get the information they need from us regarding your case. Our mission is to make sure that you are informed about both your condition and the worker’s compensation process so that working with your insurance is as simple as possible.

For more information, please do not hesitate to contact us with any questions you may have.

Referral for Specialized Care

At Tristate Pain Institute, patient satisfaction is our number one priority. We offer an array of interventional pain care solutions for patients suffering from various chronic pain syndromes. Although we pride ourselves on providing multidisciplinary treatment, there are a few services that we, as experts in pain management and neurology, choose to make the appropriate accommodations for patients needing highly specialized care.

Should your condition require additional medical care, the staff at TriState Pain Institute will work with local medical centers, clinics, and independent physicians to coordinate the following services:

Alcohol and Drug Addiction Assistance
Acupuncture and Traditional Chinese Medicine
Chiropractic Care
Massage Therapy
Physical Therapy
Electrodiagnostic Evaluations and Testing
Functional Capacity Assessments
Medical/Surgical Specialty Referrals

TriState Pain Institute prevents avoidable medical mishaps by providing a smooth continuum of care. Talk to your physician today about referrals for specialized care.