Here at the Virginia Spine Institute, our unique treatment model provides several options to our patients; all under one roof. For your non-operative needs, our Pain Management team is here to help walk you through what to expect when coming in for an injection. Spinal injections whether in the cervical, thoracic or lumbar spine can be intimidating and can cause one to be nervous. Sometimes not knowing the steps can lead to confusion and anxiety. Read on for the step-by-step process for spinal injections.

Here are the steps to ensure a smooth process:

Can I continue over-the-counter or prescription medication before my injection?

You should continue all of your pain and routine medications as usual. However, If you are on any blood thinners and/or anti-inflammatory drugs, including but not limited to: Aspirin, Coumadin/Warfarin, Plavix, NSAIDs (Ibuprofen, Naproxen, Voltaren, etc), or any other blood thinning agents- you NEED to inform the doctor or his staff when the injection is ordered. If you are on blood thinners for a specific medical condition, then we will directly communicate with the prescribing doctor to obtain permission for you to come off these medications usually 5 days prior to the procedure. Do NOT stop these medications until you receive permission from the prescribing physician.

Am I allowed to eat or drink before my injection?

If you are scheduled to have; Radiofrequency Ablation, Discography, and Spinal Cord Stimulator trials, you should NOT eat or drink anything after midnight for procedures scheduled in the morning. If your appointment is scheduled in the afternoon, you should NOT eat or drink anything after 7:30 am.

* If your procedure requires sedation and you need to take pills before the procedure, take them at least 2 hours prior with a little sip of water- just enough to swallow.

For all other procedures, it is okay to eat a light meal a couple hours prior to the procedure, as you will be lying on your stomach and a heavy meal might make you uncomfortable.

Should I arrive early for my appointment?

Arrive 15 minutes early for most procedures and 30-60 minutes early for more complex procedures, such as Radiofrequency Ablation, Discography, and Spinal Cord Stimulator trials. This will allow you to fill out the appropriate paperwork and get the prophylactic antibiotics running, if necessary.

What do I wear to my appointment?

Wear comfortable and loose clothing. For most procedures, you will be wearing your own garments, so it is advised to not wear your best clothes, at times, betadine or other agents that may stain your clothes may be used during the procedure.

I have a contrast and/or latex allergy, what do I do?

In some of the procedures we use contrast dye. Let the staff know if you have a contrast/iodine allergy. Also, if you say or think that you are allergic to latex, we will send you for blood test to confirm. FOR YOUR SAFETY, we cannot perform injections until we are certain that you are not allergic to latex.

Do I need someone to drive me to and from my appointment?

For Radiofrequency Ablation, Spinal Cord Stimulator trial, or Discography- it is a MUST that you have a driver because you will often times receive IV sedation.

Step-by step injection process:

• When the medical assistant brings you back to the fluoroscopy suite, he/she will take your vital signs. These are taken before and after for all procedures. For the more complex procedures, you will have a blood pressure cuff and pulse oximeter attached to you throughout the procedure and during recovery for continuous monitoring.
• The fluoroscope (x-ray) will be placed right above the procedure site. This machine is flexible and rotates in several different angles to allow the physician to locate the exact area of where he will inject.
• After localizing the area, the physician will use a very small needle for local anesthesia. For longer procedures, IV access will be established as route for stronger anesthetic medications.
• After injecting local anesthesia, the physician will enter the site with the appropriate needle. At this point you should not feel any local pain, but you might feel pressure. If you do have pain, inform the doctor.
• After procedure completion, pressure will be applied to the site to prevent bleeding. If betadine was used, a cleaning lotion/clean water will be used to remove the stain before dressing the site with a band-aid.
• If you feel dizzy, light headed and nauseous or have any other symptoms, you will be brought to the recovery area for monitoring until your symptoms subside. Otherwise, your vital signs will be taken post-procedure and you will be discharged. Most patients, (after spinal injections) walk out without ever needing recovery services.

What should I expect after my injection?

Most people are able to return to their normal activities, however, you should take it easy. The most common complaint is soreness at the site of the injection – in this case, ice can be used to relieve it.

Seek medical help immediately if you experience the following:

If you develop severe headaches, weakness, bowel or bladder incontinence, or a fever, notify your doctor or go to the nearest emergency facility IMMEDIATELY

Diabetic patients:

If you are a diabetic, it is essential that you monitor your blood sugar and take your medications accordingly. The steroid used in these injections can elevate your glucose level.

Medical reasons for NOT performing spinal injections include, but  are not limited to:

• Active systemic infection and/or recent dental procedure (cleaning, extraction, etc.)
• Uncontrolled bleeding disorder
• Uncontrolled blood sugar
• Very high blood pressure on the day of the injection or overall uncontrolled  hypertension
• If your physician will not allow you to come off Coumadin/Warfarin, Plavix, or other  blood thinning medications
• If you complain of chest pain and other symptoms consistent with a possible heart attack

For the most part, patients do well and the whole process goes smoothly. In the case of an unexpected situation, we are well prepared to handle the situation. At Virginia Spine Institute, we have 2 fluoroscopy suites and an ultrasound suite to perform injections. We have an entire team comprised of physicians, a nurse and medical assistants. Together, we are here to ensure that not only your pain improves, but that the entire experience is a positive one.

Ask your doctor if you are a candidate for a spinal injection or another procedure. We are always here to answer your questions and determine which injection is the most appropriate for you based on your diagnostic imaging, physical examination, and clinical evaluation.

Pregnant women frequently experience low back pain, especially after the second trimester. As your baby grows, low back pain becomes more pronounced. Between 50 to 70% of all pregnant woman will report having low back pain.

Lower Back Pain From Pregnancy Can Be Caused By The Following:

Hormonal changes: During pregnancy, certain hormones allow the muscles in the pelvis to relax in preparation for birth. The same hormones can promote loosening of the ligaments in the spine leading to back pain.

Weight gain: On average, most women will gain between 20-30 pounds, during pregnancy. The spine has to suddenly support much of the weight, which can be painful much of the time.

Posture: After the second part of the second trimester, women will typically begin to adjust their posture since the expanding uterus will shift of the center of gravity. This change can also lead to pain in the lower part of the back.

Seven Tips on How to Reduce the Likelihood of Low Back Pain During Pregnancy:

1. Avoid bending over, but rather try to squat to pick up an object during lifting.
2. Regular exercise is always important. Your physician can recommend the right exercises. If low back pain continues, adding a physical therapist to your regimen may be very useful.
3. Aquatic exercises can be very helpful during pregnancy without putting too much strain on the body.
4. Always try to use comfortable shoes with good support.
5. Always pay attention to your posture. Try not to slouch, as this can apply more pressure to your spine. When sitting, you may find that placing a small pillow behind your back, can be helpful. If you still find yourself slouching, you may want to raise your feet, until you find that your low back is as straight as possible with the least amount of pressure.
6. You are encouraged not to sleep on your back during pregnancy, but rather sleep on your side. Often times it is helpful to place a pillow between the knees.
7. Wear pants with a support waistband. These can be found in most maternity stores

It is essential to consult your obstetrician regarding any health issues you are experiencing during pregnancy or treatment options prior to initiating them.

• Most low back pain during pregnancy will resolve after you give birth.
• It is important NOT to use hot tubs during pregnancy.
• If low back pain radiates into the lower extremities or you experience any weakness, you should contact your health care provider immediately.

Flu season is upon us and in the spirit of National Hand Washing Awareness Week; we’ve put together a few tips on flu prevention.

Should I get vaccinated?

According to the CDC (Centers for Disease Control), all healthy people aged 6 months and up should be vaccinated.

Who should not get vaccinated?

• Children under the age of 6 months
• Those who have ever had a severe reaction to a previous flu shot
• Anyone with an allergic reaction to eggs

When should I get my flu shot?

Typically the best time to get the vaccine is in October and November, before flu season peaks. But it’s never too late to protect yourself; many pharmacies offer flu shot clinics , making it convenient for your busy schedule!

Is it true that you can get the flu from the flu shot?

The viruses that make up the shot are inactive, however you can experience a few side effects such as, redness, soreness, swelling at the injection site, or a low fever and achiness.

Who’s at the greatest risk this flu season?

Though we are all susceptible, young children, pregnant women, elderly, and people with chronic health conditions are at the greatest risk.

Is it a cold or the flu?

The symptoms of the common cold and the flu are very similar, if you are unsure if it is the cold or flu, you should contact your doctor with any concerns.

Did You Know?

• The flu virus can survive up to 72 hours on surfaces like doorknobs and desks
• Antibiotics are designed to kill bacteria, which mean they are not effective against the flu virus
• Nearly 22 million missed school days are due to the flu
• You can spread the flu before you even know you are sick
• It is possible to infect others 5-7 days after symptoms have developed

Prevention:

• The first step is vaccination
• Wash your hands frequently
• Disinfect common surfaces:
  • Toys
  • Handles
  • Phones
  • Kitchen
  • Bathroom
  • TV Remote

• Cough into your elbow, avoid touching your eyes, nose and mouth
• Stay hydrated

If you are sick, the best way to stop the spread of the virus is to stay home and rest up.

What tips do you have to increase your immune system and prevent the flu?

Fashion over function may not always be the case when it comes to your health. Skinny jeans or a belt that is too tight can lead to a condition called Meralgia Paresthetica. The symptoms are caused when the lateral femoral cutaneous nerve is compressed; this nerve supplies sensation in the anterior and lateral part of the thigh.

What causes Meralgia Paresthetica?

• Sudden weight gain, such as pregnancy
• Wearing tight clothing or belts
• Tight belts and clothing can lead to compression of this nerve and presents with numbness and burning pain in the front and outside of the thigh

What are the symptoms ?

• Burning sensation and pain on the lateral aspect of the thigh
• Numbness and sensitivity to touch on the outside part of the thigh
• Exacerbation of symptoms in certain positions

What is the treatment ?

Modification

• Loosen your belt and/or pants
• If this is due to sudden weight gain, then a weight loss program is recommended
• If this is caused by pregnancy, then in most cases this resolves after birth of the baby

Medications

• Certain neuropathic creams may be indicated to apply over the area of burning pain which you can talk to your physician about
• Often times, oral steroids or oral nerve pain (neuropathic) medications are necessary

Injections

• If conservative treatments above do not help solve the problem, a cortisone injection under ultrasound guidance around the lateral femoral cutaneous nerve may be helpful. This injection is performed to help reduce the inflammation around the nerve causing the painful condition

Surgery

• This is rarely indicated in the treatment of Meralgia Paresthetica
• The surgeon identifies the nerve to investigate the area of compression and then the nerve is decompressed to free the nerve from the area on which it is pinching upon.

Bottom line, make sure your clothing fits without being too tight or move your belt buckle to the next hole over to avoid this painful condition.

What condition would you like to know more information about?

If you have been experiencing unexplained muscle weakness, tingling, or numbness; your doctor may order an EMG. Read below to learn about the diagnostic procedure and what to expect:

What is an EMG?

Electrodiagnostic testing is utilized to help your physician determine if there is evidence of nerve or muscle injury that may be contributing to your symptoms. Standard electrodiagnostic testing involves two separate tests: nerve conduction studies (NCS) and electromyography (EMG).

Why is an EMG Performed?

Electrodiagnostic testing can aid in achieving a correct diagnosis to allow for implementation of appropriate treatments. Electrodiagnostic imaging can provide essential information regarding an underlying nerve disorder, such as entrapment neuropathies, carpal tunnel syndrome, peroneal neuropathies, polyneuropathies, brachial, and lumbar plexopathies. Neuromuscular disorders such as myasthenia gravis, Lambert Eaton syndrome, and botulism, as well as certain myopathies, can also be diagnosed using these studies. Radiculopathy is one of the most common reasons for having an EMG ordered. Radiculopathy can be caused by nerve root compression in the cervical, thoracic, or lumbar spine, but most commonly occurs in the cervical spine. Radiculopathy is a condition in which the nerve root is irritated and may present as weakness, pain, or numbness. The EMG test helps to clarify the cause of your symptoms by confirming and localizing the presence of nerve or muscle damage when exam findings or other diagnostic tests are not clear. The EMG often helps your physician to determine the exact location of nerve damage, the severity of damage and provides information on when the injury may have occurred. Information gathered by these studies is often useful in determining appropriate diagnoses and treatment options.

How is an EMG Performed?

In most cases, the EMG is performed after the NCS, as the information gathered during the NCS aids in the appropriate selection of muscles to be tested in the needle portion of the examination. The NCS measures the responses obtained by activating certain nerves in the upper and lower limbs. The choice of nerves to stimulate is contingent upon the presenting signs and symptoms.  To perform the NCS, the electromyographer will use a stimulating device to deliver an electrical impulse along the nerve being tested. The delivered shock will feel similar to being shocked by static electricity (some shocks may feel stronger). The signal transmitted by your nerves are then recorded and displayed on the computer screen for analysis.After the NCS is performed, the electromyographer will perform a needle analysis of individual muscles in your arm, leg and/or along the spine. The needle is about the same size as an acupuncture needle. You will see and hear this electrical activity on the screen as your electromyographer will analyzes the activity. Combining the information from both tests, allows your physician a great deal of insight regarding the health of your peripheral nervous system from the spine all the way to the tips of your fingers and toes.

Are There Any Risks?

In general, some parts of the test (electrical shocks during NCS and needle insertion during the EMG) may be a little uncomfortable. There is no risk of serious injury to the nerve or muscles from having this test done. The vast majority of patients who do experience an increase in their pain after the test do very well with simple pain management strategies.

How Do I Prepare?

On the day of your test you may still wash your skin with soap and water, but do not rub any topical lotions on the arms or legs that are being tested. Also, if you are prone to having cold hands or feet, try to wear warm gloves or socks on the day of your test.

Have you had an EMG? What advice would you share?

1.  Proper Footwear:

• Pay attention to the shoes you are wearing, even if it is a brisk walk around the block.
• Footwear should provide comfort and adequate padding with heal support (ie; avoid flip flops).

2.  Leash Technique:

• The leash should be a comfortable distance so that your arms are not overstretched, allowing slight flexion at the elbows.
• Allow flexibility with the leash to avoid over extension if your dog suddenly lunges forward; however, try to not let your dog get too far ahead of you.
• Avoid erratic movements to avoid injury. Sudden extension can injure your back, particularly the facet joints.

3.  Maintain Posture:

• Use your core to stand straight and avoid too much flexion or extension.
• Walk at a steady pace.
• Turn the dog using your body.

4.  Listen to your body:

• Do not go to the point of exhaustion, but rather gradually increase the distance every 1-2 days.
• Take frequent breaks if you need to; it gives your dog a break too.
• Treat walking just as you would any other physical exercise. Make sure you stretch before and after to avoid pulling a muscle!

5.  Pick up after your dog:

• Bend with your knees and use your leg muscles.
• Use your core for stability.

Walking regularly not only benefits your dog, but you as well. It can help alleviate symptoms of chronic low back pain. So grab the leash and enjoy the warm weather; Fido and your back will thank you!

What is your biggest physical challenge when walking your dog?

WEEDING

Weeding often requires prolonged sitting or bending over. To avoid excessive bending, it is recommended to use a stool (a simple low stool will often do the trick) to sit on, which will reduce the amount of pressure put on your low back. This is also a useful technique if one has knee and/or hip pain.

DIGGING

Digging is a critical gardening movement that requires the right tools to get the job done safely and efficiently. Make sure you have a shovel with sharp edges to reduce the amount of force needed to scoop the dirt. The handle of the shovel should also be long enough to avoid excessive bending. Maintain good posture while using a shovel, and if you find yourself using too much pressure, try to wet the soil to loosen it up. Don’t twist too much when dumping out the soil, but rather move a few steps to get to the dumping ground.

LIFTING

Prolonged lifting of heavy bags of soil and mulch can take a toll on your back. Rule of (green) Thumb is to always use your hips to lift up, as these muscles are typically much stronger than your low back muscles. Furthermore, bend at the knees and use the hips to come back up; do not bend your waist. Many people invest in elevated garden beds to avoid excessive bending. If something is too heavy, don’t be afraid to ask for help! Your back will thank you later.

LAWN MOWING

A well manicured lawn is often the finishing touch to a picture perfect landscape. It is imperative to maintain proper posture while using a lawn mower as poor technique can lead to increase strain, and in turn, low back pain. Also pay attention to your arm position. Proper form allows a slight bend at the elbow with the handle at a comfortable level (not too high or low).

Gardening basics for every green thumb:

• Make sure you are conditioned and ready for spending prolonged time in the garden. Don’t rush into gardening after long periods of inactivity.
• Planting perennial flowers and plants is a great way to avoid additional time in the garden every season.
• Make sure you are well hydrated while spending hours outside. It is a good idea to wear light colored clothing and a hat, and plant in shaded areas.
• Listen to your body and take breaks every 15-20 minutes to stretch.
• Make sure to have long enough handles on your tools to avoid excessive bending.

What tips can you share from your gardening experience that will offer others a pain free garden workout?

*If you continue to suffer from low back pain despite these techniques, it is important to contact your physician prior to continuing to garden.

Living with chronic pain is not easy, and with time, can really affect one’s lifestyle. In fact, the psychological effects of chronic pain are often times just as significant as the painful physical condition itself. Emotional effects of chronic pain include irritability, depression, and anxiety.  Chronic pain can also affect one’s ability to interact with others and maintain stable relationships. To help overcome these common effects I have included some coping strategies which I hope you find useful.

Emotional effects of chronic pain include:

• Losing the ability to do the things normally enjoyed
• Altering the way one interacts with others
• Difficulty maintaining stable relationships
• Depression and anxiety
• Difficulty concentrating
• Irritability and short temper
• Weight gain

Patients with chronic pain are not necessarily diagnosed with depression or anxiety, but dealing with a condition leading to chronic pain can cause a patient to feel depressed and anxious.

5 Helpful Tips When Dealing with Chronic Pain

It is very important to develop coping skills. Some people are able to live a relatively healthy lifestyle despite the pain, and others are unable to do so. It is very important to understand that you are not alone.  In order to deal with chronic pain, these are a few tips to keep in mind…

1. Exercise
Although this may be difficult, under the guidance of a certified physical therapist, a proper home exercise regimen can be tailored to an individual.

2. Eat healthy
Proper nutrition can add to a healthy life-style in general.

3. Learn to relax
Take some time to relax completely (although this can be difficult at times). Meditation and yoga are great modalities to help one relax, especially while listening to your favorite peaceful music.

4. Get a proper night’s sleep
Sleep disturbance is very common amongst patients with chronic pain. It is important to try to relax, to not eat heavy meals prior to going to bed, and to wind down after a long day.

5. Try alternative treatments
Transcutaneous electrical nerve stimulation (TENS units), massages, acupuncture, and other modalities are often useful.

Pain psychologists and counselors can be beneficial for most patients with chronic pain. Although narcotics are very useful in treating many painful conditions, they are only part of treating chronic pain.   It is important to realize that medications do not cure pain, but rather are there to allow one to function better than they would without medications.

Speak with your doctor or pain specialist if you are having a hard time coping with chronic pain. If chronic pain starts affecting your personal life and self image, or interfering with your work and relationships, it is important to seek the proper medical assistance.

Talk to us, which coping strategies do you find most successful in dealing with chronic pain?

Shovel Away Your Low Back Pain This Winter. Snow shoveling often leads to low back injuries, so it is important to practice proper shoveling techniques to avoid these injuries.

1. PROPER STRETCHING:

• Warm Up: Think of shoveling like exercise; never start shoveling without a quick warm up! Get your heart rate up with a short walk or jog on the tread-mill or with a bike ride on a stationary bike.

• Stretch: Focus on stretching the areas that are most engaged during shoveling: hamstrings, shoulders, and low back.
  • Stretch #1: Touch your fingers to the ground (or as far as you can go without bending your knees)
  • Stretch #2:  Raise your arms straight above your head and slowly stretch your neck on each side.

2. SELECT THE RIGHT SHOVEL

• Sharp Blade: Just like a good knife, a sharp shovel blade allows you to move the most amount of snow efficiently.
• Light Weight: A light snow shovel will alleviate much of the weight required for lifting (don’t underestimate the weight of snow by itself – it can get dangerously heavy).
• Correct Length: When choosing the length of the shovel, make sure you are not bending forward, or leaning back too much.
  • Pick a shovel that has an adjustable handle length (so you can share the duty with other family members!).
  • Before purchasing your shovel, try it out at the store by simulating the act of shoveling.

3. LIFTING TECHNIQUES

• Only lift when absolutely necessary! If you can push the snow to the side for a plow to pick up or for it to melt.
• Bend at the hips and knees – never the low back.
• Engage your abdominal muscles and keep your back straight; Don’t twist your back when changing positions
• Position one hand on the handle and the other near the shovel blade.
• Don’t throw large amounts of snow from the shovel; rather walk to the location where you want the snow deposited.
• Wear boots with proper gripping and apply sand or salt on the snow to prevent falls.

LISTEN TO YOUR BODY

• Just like when you lift weights, take breaks during sets, ie; shovel for 10-15 minutes, and then take a 5 minute break.
• Let your body dictate how many breaks you need and always stretch during them.
• STOP shoveling if you feel short of breath, dizzy, or experience chest pain. If these symptoms do not subside, go to the nearest emergency room or call 911.
• STOP if you experience sudden sharp low back pain or pain shooting into your legs.

Using these simple guidelines can allow you to have a clean driveway and a healthy back!

Which tip did you find most useful in accomplishing  pain free shoveling?

If this type of pain interferes with activities of daily living during you menstrual cycle, it’s important to understand why it happens and how to cope with and manage the pain.

What Causes Low Back Pain During Menstruation?

Low back pain during menstruation is typically muscular in nature and thought to be caused by hormone changes. Prostaglandins (hormones released during a menstrual cycle to promote uterine contraction to shed the uterine lining) can affect the lower back muscles.  An excess of prostaglandins causes dysmenorrheal or painful menstruation.  Heavy contractions can lead to low back pain, as the pain can radiate from the lower abdomen into the low back.

Women with endometriosis may also experience low back pain during the menstrual cycle. If this is of concern, you may want to talk to your doctor about this diagnosis and proper treatment options.

8 Tips to Reduce Painful Cramping and Low Back Pain:

1. Some women benefit from starting over the counter acetaminophen or anti-inflammatories, such as ibuprofen or naproxen, a couple days prior to menstruation.
2. Exercise regularly. Studies show that women who exercise on a regular basis have less painful menstrual cramps and low back pain.
3. Maintain a healthy diet and take nutritional supplements with vitamin B and magnesium
4. Drink plenty of water to stay hydrated.
5. Apply heat or take warm baths.
6. Avoid caffeine and chocolate.
7. Avoid alcohol intake and smoking.
8. Some women may require birth control pills to help with menstrual pain.

If your low back pain lingers past the menstrual cycle or you develop leg pain or weakness, you should seek medical attention, as this may be more than the typical low back pain stemming from prostaglandin release during menstruation.

Do you experience back pain associated with your menstrual cycle? If so, share your tips with us on how you cope with painful menses.