Anesthesiologists have been performing nerve blocks for surgical anesthesia for centuries to allow a patient to undergo an operative procedure more comfortably with less general anesthetic and therefore fewer side effects. Modern anesthesiologists prefer to administer more regional anesthetics (i.e., anesthetizing only a specific region of the body) over a general anesthetic whenever possible because we find that patients have less pain, nausea and delirium postoperatively, as well as shorter, if not outpatient, hospital stays. Typical types of surgery that would fall into this category are surgeries on extremities including total hip and knee replacements; leg, foot, arm, shoulder and hand surgeries.
The pain management specialty was borne from the desire to help more patients who are not having surgery, but who are in pain nonetheless, with the same techniques. By offering interventional techniques such as nerve blocks and steroid injections, we can treat outpatient pain problems without having to rely on or use high dose oral pain medications. The most commonly performed procedures are epidural steroid injections for neck, mid-back and low back pain. Herniated discs and stenosis (spinal arthritis) can cause inflammation and swelling of spinal nerves to create severe pain in the neck, arms, low back and/or legs. The injection of steroid medication into the epidural space, which surrounds the nerves, helps reduce the swelling and inflammation and pain. We often inject a local anesthetic, aka “numbing medication,” with the steroid for some immediate pain relief, which is what makes the injection a “block.” Oftentimes the anti-inflammatory effect of the steroid provides long lasting pain relief for months or years; however, occasionally the pain relief effect may only last days or weeks. The difference in the result from person to person depends on multiple factors including: severity of the disc herniation or arthritis, weight burden on the spine, muscle tone surrounding the spine, and amount of inflammation, to name a few. Unfortunately, these steroids don’t cure the ultimate cause of the pain, but they can and do, for most people, improve function and reliance on pain medications. The injections can safely be repeated if the pain returns, however, the best way to avoid future pain exacerbations is to optimize spine health with weight reduction, core strength training and stress reduction/management.
As with any medical technique or recommendation, the benefit of the treatment should far exceed the risk. Cervical and thoracic epidural injections inherently carry more risk to perform because the spinal cord can be injured if they are not performed correctly. The spinal cord terminates at L2 and exists as long spaghetti-like nerve endings below this level, so lumbar epidural injections carry less risk of spinal injury, however all injections should only be performed by specialty trained doctors. Patients who are at higher risk for complications from injections include those with diabetes or bleeding disorders or those who are taking blood thinners. If steroid injections are done too frequently, side effects can occur including adrenal suppression (the body doesn’t make its own steroid hormones), early cataracts and hormonal imbalances.
My pain management philosophy is to use a balance of treatment options so the patient isn’t at higher risk from any one particular type of treatment. Also, the complexities of chronic pain are better addressed by using a treatment plan that is directed at alleviating more than one aspect of the pain. Oftentimes pain, anxiety, depression, insomnia, isolationism, anger and embarrassment are intertwined and there just isn’t one type of medication or injection or treatment that will make all of those symptoms resolve simultaneously. The best treatment plan is one that will reduce pain and increase quality of life and function for the short term and the long term with the least side effects.