If analgesics and non-invasive treatments do not help sufficiently or are undesirable, injection treatment can help to relieve the pain. Targeted injections like epidurals, joint or muscular  injections can have a profound pain relieving during acute pain attacks or flare-up periods.

Injections target structures (such as particular joints or disks for example) that show up as changed in X-ray scans or numb nerves that transmit painful sensations.


Injections with Local Anaesthetic and Cortisone

Diagnostic injections work by numbing (with local anaesthetic) and reducing inflammation and irritation (with cortisone).

The relief can be profound but is often time limited. It is important to understand that injections are not a lasting cure.



RF (radiofrequency) procedures

If diagnostic injections are temporarily successful then RF procedures can be performed to disable transmitting nerves for longer periods with targeted stimulation (pulsed RF) or heat (conventional RF).



When to consider pain relief injections

  1. - if you have an acute, disabling pain attack not responding to pain killers

  2. - if other treatments haven't helped sufficiently

  3. - if your pain is limited to one or two body regions (not widespread pain)

  4. - if you cannot tolerate side effects of long-term pain killers

  5. - during a flare-up period of disabling pain

  6. - if you need extra relief prior to physical treatment/ rehabilitation

  7. - if you need extra pain relief for travel, return to work or other important events



For how long do injections work?

The effect from local anaesthetic and cortisone injections tends to last for 1-3  months on average (with a range from just days to more than year).

The effect from RF procedures, done as second step treatment, lasts for 6-12 months on average, with the same range as above.

Procedures can principally be repeated if they have been temporarily successful. A limiting factor can be a decreasing effect over time. You may also want to avoid becoming dependent on repeat injections, so they should be performed judiciously.



Do pain relief injections have risks and side effects?

Serious risks are very rare. The most common problem is initial soreness and short-term numbness or weakness from the local anaesthetic. Depending on what kind of injection may be suitable for you the risks and side effects will be explained in detail and you will receive detailed written information at your appointment.



What kind of injections and procedures are available on the Isle of Wight?

  1. - Epidural injections

  2. - Spinal nerve root blocks

  3. - Spinal facet joint injections

  4. - Joint injections (hip, knee, sacro-iliac joints)

  5. - Suprascapular nerve blocks

  6. - Scar infiltrations

  7. - Trigger point injections with cortisone or Botox

  8. - Conventional radiofrequency procedures

  9. - Pulsed radiofrequency procedures


The information given on this website is meant to support a medical pain specialist appointment. It should not be taken as stand-alone universal advice and may be incomplete or unsuitable for your specific circumstances. It cannot replace medical assessment and advice, and should not be used as such. The website is operated from the UK and meant for UK residents.


Copyright © 2015 by Dr Michael Luckmann

Pain relieving injections

EPIDURAL INJECTIONS


Background information

The epidural space is a tube-shaped canal inside the spinal column. It contains the spinal cord among other structures. All major nerves branching our from the spinal cord pass through the epidural space.


Epidural injections affect these nerves and, to a lesser extent, discs and joints of the spine.  Nerves inflamed by a disc bulge or prolapse, scar tissue or arthritis are numbed temporarily by weak local anaesthetic. By adding cortisone local inflammation is soothed and swelling is reduced. Cortisone comes in tiny crystals which are slowly absorbed over a few months time and so provide an ongoing effect.

Please note, that the cortisone part of the injection - although a fully licensed medicine – has not been licensed for injection into the epidural space.  It has however been used safely in this way for many years, and is regarded as standard by most pain specialists. If you have more questions about this, please ask your doctor.


How is the injection performed?

An epidural injection can be given into the neck, middle- or lower back or between the buttocks (caudal epidural).

The procedure usually takes between 10-30 minutes to carry out in an operating theatre. It is performed in a sitting or lying position under local anaesthesia. Most epidurals are performed under x-ray guidance.

X-rays can be harmful and the dose is kept to a minimum.

For women of childbearing age – with certain exceptions - these injections need to be performed within 10 days following a menstrual bleeding. Please tell your doctor if your appointment does NOT fall into this time period.


What are the outcomes?

60-80% of patients experience 50% or better pain relief.  Leg/ arm pain is usually relieved more effectively than lower back/ neck pain.

Often the pain relieving effect is temporary, with an average duration of several months. If successful, the injections can be repeated 2-3 times per year. However, repeating epidural injections is not without problems. Your doctor will discuss this with you.

5-10% of patients report an increase of pain in the days after the injections. This is caused by local bruising and is “normal” as long as there are no signs of an infection (red and hot injection site, pus, fever). It usually lasts for several days but in some cases can take several weeks to settle. Please take pain medicines (paracetamol, anti-inflammatories etc.) and reduce your normal amount of activity during this period.


What are the risks or complications of an epidural?

Some patients have only marginal, very short-lived or no pain relief at all from epidural injections. As outlined above, a temporary increase of pain is possible. Also, a short period of weakness and numbness of legs (lower back injection) or arms (neck injection) can occur.

A more common complication (10-20%) is a headache of varying intensity, which can rarely last for several days and can be disabling. Other rare risks include drops in blood pressure and problems passing water for several hours following the injection. Damage to nerves or the spinal cord (with concomitant paralysis) as a result of an infection or bleeding inside your spine is extremely rare (1:100,000 or less). In the unlikely event of increasing numbness in your legs/ bottom/ arms or if you develop problems with passing water or opening your bowels you need to get in contact with your doctor without delay.


What do I need to do before my hospital admission?

Please continue to take your pain killers as usual on the day of treatment. In the last 2 hours before your procedure you should restrict yourself to light snacks and drinks only. Avoid large meals on the day of your treatment.


Inform your doctor about your regular medicines. Anti-coagulants from the list below have to be stopped 5-7 days prior to the injection.

Aspirin (any dose), Clopidogrel (Plavix™)

Warfarin

Abciximab (ReoPro™), Dipyridamole (Persantin™, Asasantin™), Eptifibatide, (Integriline™), Tirofiban (Aggrastat™), Acenocoumarol (Sinthrome™), Phenindione


What should I do after the injection?

After any initial flare-up has settled you need to slowly increase your activity level. Remember, that an epidural does not directly improve any joint stiffness or muscle tenderness. Your muscles, joints and ligaments require gradual stretching and strengthening (“training”).

If you do not increase your activity level, pain reduction will likely be incomplete and probably rather short-lived.

FACET AND SACRO-ILIAC JOINT INJECTIONS


Background information

Facet joints are small joints in the spine. They come in pairs and are located throughout the spine from neck to bottom. The sacroiliac joints are two large joints between the sacral bone and the pelvis.

Like other joints in the body, they can be the origin of pain caused by inflammation (arthritis). The pain often radiates into buttocks, hips, groins or legs down to the knee level.

Injections into or around the facet/ sacroiliac joints and the associated nerve can numb them temporarily (local anaesthesia). By adding cortisone to the injected solution a reduction in swelling and inflammation can be achieved.

How are the injections performed?

The injections will usually take around 30 minutes to carry out in an operating theatre, depending on the number of joints injected. Up to 6 facet joints and/or the two sacroiliac joints can be injected in one session. 

The procedure is performed under local anaesthesia with optional sedation. If you require sedation the procedure and recovery period will take longer and you need to starve as for other operations (6 hours for solid food, 2 hours for clear drinks).

During the procedure, you will lie on your front. Afterwards you should lie on your back for another 30 minutes.

The injections are done under x-ray guidance. X-rays can be harmful and the dose is kept to a minimum.

For women of childbearing age – with certain exceptions - these injections can only be performed within 10 days following a menstrual bleeding. Please tell your doctor if your appointment does NOT fall into this time period.

What are the outcomes?

60-70% of patients report at least 50% or better pain relief. Often the pain relieving effect will be temporary, with an average duration of several months. If successful an RFD procedure can be considered for a longer effect as next step.

It is possible that your pain will increase to start with in the days after the injections. This is caused by local bruising inside tightened muscles and is “normal” as long as there are no signs of an infection (red and hot injection site, pus, fever). It usually lasts for several days but in some cases can take several weeks to settle. Please take pain medicines (paracetamol, anti-inflammatories etc.) and reduce your normal amount of activity during this period.


What are the risks or complications of facet joint injections?

Some patients will have only marginal, very short-lived or no pain relief at all from facet joint injections. As outlined above, a temporary increase of pain is possible. General risks are infection and bleeding (rare). An injection around a nerve root is very rare and can result in temporary numbing or weakness of a buttock or leg. Injecting into a blood vessel can be very dangerous but is extremely rare.

What do I need to do before my hospital admission?

Please continue to take your pain killers as usual on the day of treatment. You should stop eating for 2 hours (or 6 hours if you require sedation) before coming to hospital but can drink clear fluids as desired (stop for two hours if you require sedation). Avoid large meals on the day of your treatment.


Inform your doctor about your regular medicines. Anti-coagulants from the list below and some other drugs may have to be stopped 5-7 days prior to the injection.

Aspirin (any dose), Clopidogrel (Plavix™)

Warfarin

Abciximab (ReoPro™), Dipyridamole (Persantin™, Asasantin™), Eptifibatide, (Integriline™), Tirofiban (Aggrastat™), Acenocoumarol (Sinthrome™), Phenindione

What should I do after the treatment?

After any initial flare-up has settled you will need to slowly increase your activity level. Remember, that the injections improve pain arising from arthritis but do not directly improve joint stiffness or muscle tenderness. Your muscles, joints and ligaments require careful stretching and strengthening (“training”).

If you do not increase your activity level, pain reduction will likely be incomplete and probably rather short-lived.

You can train your muscles by doing a little more every day and enhance your stretching exercises. Again, pacing is vital. If you do too much too soon, the pain is likely to come back early.