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Common Pain Management Procedures



  • This is fantastic information. Thank you so much for taking the time to create this post.
  • Thanks Bruce
    what do you know about interlaminar fenestration?
    From what I can find out, it sounds like a less invasive version of laminotomy.
    Perhaps it is only a term used in some parts of the world (I'm in the UK)

    I've just had it used on my spine, levels L3/L4 and L5/S1 to decompress nerves and cord, at the same time as laminectomy and PLIF on L4/L5 to treat my spondylolisthesis.

    Keep up the good work on this site :-)
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  • I've had all kinds of epederal injections, facet joints, rhizotomy's, plus 6 surgeries. with 3 fusions. I tried the pain patch & no luck, now we are going to try the pain pump. Anyone out there have used this?
  • Well done Bruce, this info is useful for all members from the newbie, to the most seasoned members
    One type of injection I did not notice is the caudal epidurals. I only mention this as I have had 5 over the past 5 years. It is not as widely practiced as the others you mentioned. They were helpful for me in providing meds, steroids, and other good stuff to multi-level lumbar region (mine were actually performed by NS not PM). Also was done in an OR on a call table that tilted to aid in proper distribution of meds.

  • ** meant COOL table, that tilted.
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  • Thank you Sir, thank you very much actually, that is very informative and helpful for us to know the facts about pain management. I've recently had injury in my arm and there is a lot of pain in arm these days, so I've found your article and this will be very helpful.
  • Bruce said:
    I have compiled a summary of the various pain management procedures: starting from conservative through to surgical. I hope that this is useful information for some of you. These have been grouped as below, as doctors will normally initially treat back pain with conservative procedures first and if these don't work move to medication, then minimally invasive techniques and finally surgery:

    1. Conservative
    2. Medication
    3. Minimally Invasive Techniques
    4. Surgery

    Of course, the suitability of some of these procedures depends upon the patient's specific condition.

    Conservative Treatments

    Exercise can be very beneficial for mild to moderate back pain, but if you have severe back pain be very careful, and don't do too much.

    Aerobic exercise
    Non weight-bearing exercises such as upright cycling, cross-training in a gym, or any sort of exercise in water are very beneficial.

    Swimming is beneficial - backstroke with gentle swinging of your arms puts the least strain on your spine. If your neck is OK you can do breast stroke or front crawl. If you can't swim just get into the shallow end and try as best as you can to jog from one side of the pool to the other.

    Cycling is very good non-impact, non-weight-bearing exercise so long as you do not adopt a racing position, which would put considerable strain on your lower spine and neck.

    Yoga and Pilates
    If you have a good basic level of strength, technique, and flexibility you may benefit from yoga but you should take advice. Pilates is excellent to improve your flexibility, core stability, balance and muscle strength.

    Physiotherapy is the core treatment for patients with spinal, and musculoskeletal problems. Physical therapy interventions may include: Spinal and extremity manipulation; therapeutic exercise; electrotherapeutic and mechanical agents; functional training; provision of aids and appliances; patient education and counseling; documentation and coordination, and communication.

    Osteopathy and Chiropractic
    These are manipulation-based techniques that focus more on function than structure. They can be beneficial in many pain problems, and are often recognised by insurance companies. However, if you have severe back pain, please be very cautious about using a chiropractor.

    The following links on this site give additional information:


    Non-steroidal anti-inflammatory drugs (NSAIDs)
    These are first generation drugs such as ibuprofen (Nurofen) or diclofenac (Voltarol). They can be very effective at relieving musculoskeletal pain and are generally well tolerated although some patients can get side effects, particularly gastrointestinal bleeding and fluid retention.

    COX-2 inhibitors
    These are second-generation anti-inflammatory agents, which have been available for the last few years. There are many drugs available in this class, for example Arcoxia, Celebrex or Bextra. They are generally better tolerated than NSAIDs and are associated with less risk of gastrointestinal bleeding.

    Mild opioids
    This group of drugs includes, in roughly increasing strength, codeine, dihydrocodeine, and tramadol (which also has non-opioid analgesic properties). Codeine and dihydrocodeine preparations are often given in combination with paracetamol.

    Strong opioids
    This group of drugs includes buprenorphine, morphine, and fentanyl. These drugs are used for pain that has not been adequately controlled by weaker drugs.

    Anti-neuropathic treatments
    Neuropathic pain (nerve pain) is very common in many pain problems from spinal pain through to cancer pain. Its incidence is often underestimated and it is important that you realise that it does not respond well to treatment by normal painkillers. You will likely need special drugs, such as amitriptyline, carbemazepine, gabapentin, or pregabalin.

    The following links on this site give additional information:
    Refer also to http ://messageboard.spine-health.com/viewtopic.php?id=3392

    Minimally Invasive Techniques

    Acupuncture (not sure which category this belongs in)
    Acupuncture is designed to inspire shifts in the body and mind by increasing circulation in places of tightness, weakness, and pain. By addressing issues of tissue congestion and stagnation, movement and communication of bodily fluids, blood, lymph and the nervous system is encouraged.

    Facet rhizotomy injection
    In some low back pain programs, if three facet block injections provide good but temporary relief of the patient's pain, a facet rhizotomy injection may be recommended. The purpose of a facet rhizotomy injection is to provide lasting low back pain relief by disabling the sensory nerve that goes to the facet joint.

    Facet joint injections
    Facet joint injections are performed for facet joint pain. Facet joints can be injected with long acting local anaesthetic and anti-inflammatory steroids, which can alleviate facet joint pain for long periods.

    Facet joint denervation
    This is a straightforward procedure that is normally carried out if you have had a successful result from facet joint injections. Special needles are carefully placed under continuous fluoroscopy so that their tips lie exactly on the nerves that carry pain signals from the facet joints. Radiofrequency energy is then passed through the needles so that that tissue at the tip is heated to about 80 degrees C for about a minute. This coagulates and inactivates the nerves.

    Pulsed radiofrequency treatment
    Passing alternating radiofrequecy energy through tissues without significantly heating it can selectively inactivate pain-carrying nerve fibres, which tend to be smaller in diameter than the fibres that control muscles and allow normal sensation. Conventional radiofrequency treatment results in the coagulation of all tissues at the tip of the needle, including all nerve tissue. In most situations this does not matter, but in some situations it is important to maintain as much normal nerve function as possible.

    Discography involves the insertion of a thin needle into one or more discs. Then either saline is injected into the disc to see if it is painful, or radio-opaque contrast dye is injected and x-rays will be taken to show the internal structure of the disc.

    Epidural steroid injection
    The word 'epidural' simply refers to a layer of supporting tissue outside the spinal cord. In an epidural a solution of long acting local anaesthetic, long acting anti-inflammatory steroid, and sometimes other pain modifying drugs is injected into the epidural space in the spine.

    Transforaminal epidural injection
    This is an important adjunct to epidural steroid injection and the two are normally done together. If you have lumbar radiculopathy or cervical radiculopathy, you will probably also have one or more transforaminal epidural injections.

    Sacrolliac joint steroid injection
    In the first instance a solution of long-acting local anaesthetic, long acting anti-inflammatory steroid, and sometimes other pain modifying drugs is injected into one or both joints. If this is successful the joint can then be denervated in a similar way to facet joint denervation.

    Selective nerve root block (SNRB) for diagnosis and back pain management
    Another common injection, a selective nerve root block (SNRB), is primarily used to diagnose the specific source of nerve root pain and, secondarily, for therapeutic relief of low back pain and/or leg pain.

    Lumbar sympathetic block
    Injection needles will be positioned and then there are three main ways to produce the block: injection of a long acting local anaesthetic to produce a diagnostic block to safely see if your pain can be treated this way; injection of a neurolytic substance such as phenol or alcohol to destroy the lumbar sympathetic nerves; and the use of radiofrequency energy to similarly destroy the nerves in a highly controlled way.

    Stellate ganglion block
    The stellate ganglion is a collection of autonomic sympathetic nerves, which lies in front of the spine at the level of your larynx. It can be a site where pain signals from the face, heart, or arm are processed. It can therefore sometimes be useful to block it.

    Dekompressor discectomy
    The Stryker Dekompressor is a relatively new technique for the decompression of contained lumbar herniated discs. A special device the size of a needle is inserted into the affected disc. This then rotates like a drill removing some of the nucleus of the damaged disc, thus decompressing it and allowing the bulge to reduce. This in turn reduces the pain from both the disc and the nerve root.

    Percutaneous disc nucleoplasty
    This is a relatively new technique for the decompression of contained lumbar herniated discs. A special device the size of a needle is inserted into the affected disc. This probe has radiofrequency electrodes at its tip and is slightly angled. It is moved around inside the disc vapourising a very controlled amount of disc nucleus, typically 1 - 2 ml.

    It involves the injection of bone cement into the crushed vertebral body, which stabilises it and reduces pain by reducing movement at the fracture site. It is well established and straightforward to perform, usually as a day-case procedure. A newer alternative treatment is Kyphoplasty.

    It involves the insertion of needles into the damaged vertebral body, through which balloons are passed. These are inflated under high pressure, which expands the VCF and corrects the deformity. Once corrected, liquid bone cement is injected into the vertebra to permanently fix the restored shape.

    Spinal cord stimulation
    Spinal cord stimulation can be very effective at treating nerve pain (neuropathic pain) and dysfunction from a number of different conditions. It has been shown to be particularly effective at relieving resistant nerve pain such as lumbar radiculopathy following spinal surgery. It involves the implantation of a wire and a device the size of a matchbox.

    Sacral nerve root stimulation
    This is a new and effective treatment for a number of loosely related bladder and bowel control problems. The other main treatment alternative is spinal cord stimulation. The main risk is infection, which can occur in up to 5% of patients.

    Intrathecal pump implant
    Intrathecal drug delivery devices are advanced pain management systems for patients whose pain cannot be adequately be controlled by conventional oral or systemic analgesics. Delivery of strong painkillers such as morphine directly into the cerebrospinal fluid can avoid many of the unpleasant side effects of conventional drug delivery.

    The following link on this site give additional information:


    For people with disk problems, the surgeon forms a "window" in a portion of the outer ring of the disc. Then the surgeon removes a portion of the disc nucleus, releasing the pressure on the nerve. Some surgeons perform a microdiscectomy, which may require removal of only a small portion of the lamina (part of the vertebrae).

    A laminectomy removes the entire lamina. Removal of the lamina allows more room for the nerves of the spine and reduces the irritation and inflammation of the spinal nerves. The lamina does not grow back. Instead, scar tissue grows over the bone, replacing the lamina, and protects the spinal nerves.

    There are two main types of spinal fusion, which may be used in conjunction with each other:
    Posterolateral fusion places the bone graft between the transverse processes in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the pedicles of each vertebrae attaching to a metal rod on each side of the vertebrae.

    Interbody fusion places the bone graft between the vertebra in the area usually occupied by the intervertebral disc. In preparation for the spinal fusion, the disc is removed entirely. A device may be placed between the vertebra to maintain spine alignment and disc height. The intervertebral device may be made from either plastic or titanium. The fusion then occurs between the endplates of the vertebrae. Using both types of fusion is known as 360-degree fusion. Fusion rates are higher with interbody fusion. Two types of interbody fusion are:

    1. Anterior lumbar interbody fusion (ALIF)- an anterior abdominal incision is used to reach the lumbar spine.
    2. Posterior lumbar interbody fusion (PLIF) - a posterior incision is used to reach the lumbar spine.

    In most cases, the fusion is augmented by a process called fixation, meaning the placement of metallic screws (pedicle screws often made from titanium), rods or plates, or cages to stabilize the vertebra to facilitate bone fusion. The fusion process typically takes 6-12 months after surgery.

    A procedure that removes a part of the facet (a bony structure in the spinal canal) to increase the space.

    A procedure that removes the foramina (the area where the nerve roots exit the spinal canal) to increase the size of the nerve pathway. This surgery can be done alone or with a laminotomy.

    A laminectomy removes the entire lamina. Removal of the lamina allows more room for the nerves of the spine and reduces the irritation and inflammation of the spinal nerves. The lamina does not grow back. Instead, scar tissue grows over the bone, replacing the lamina, and protects the spinal nerves.

    A procedure that reaches the cervical spine (neck) from the back of the neck, which is then reconstructed to make more room for the spinal canal.

    A procedure that removes only a small portion of the lamina (a part of the vertebra) to relieve pressure on the nerve roots.

    A procedure that removes a disc through a very small incision using a microscope.

    An elective surgical procedure, performed under general anesthesia, in which a bone is cut or a portion is taken out in order to fix a bad bone alignment, to shorten or lengthen the bone, or to correct damage due to osteoarthritis. An Osteotomy is needed when a bone has healed badly or crooked, or when a deformity is caused by disease or disorder.

    The following link on this site give additional information on surgery:

    Return to FAQ

    nice and helpful post...
  • I had Rfa procedure done on Monday and although it was quite painful in certain areas a my doctor inserted into some of he neves, i am in a more pain now. I understood hs would be the case but now I have excruciating groin pain and pain in my sacroiliac joint which is abnormal by he way. I currently taking 60mg of morphine twice a day but this not stopping he pain and have been taken it here times a day but now afraid to run out before I supposed to.
  • I've had my pump now for 23 days and I am at a loss about what to think. They are having trouble titrating my flow up because I become to sedated. I know it hasn't even been a month yet, but my pain is chasing me around and around. Does anyone have any advice?
  • Bruce said:
    It was my pleasure :)
    I really appreciate this. I was wondering if you have a listing for DLIF inter body lumbar fusion?
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