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.

I was recently asked about a condition called foot drop, what the causation is and how it is treated. To start, let’s define what foot drop is; it is a term used to describe the loss of ability to pick one’s foot up.  The medical term for this is dorsiflexion of the foot or raising the toes off of the ground.  When one suffers from foot drop, they tend to trip over their foot because the ankle is unable to keep the toes off of the ground; therefore, as they walk, their foot drops down and they trip over their toes.  Not only is this problematic when one tries to walk, it can create worse problems because people are more susceptible to falling.

What Causes Foot Drop?

1.   Severe compression of the nerves in the low back.

The specific nerves would be L4 or the L5 nerve.  These are the nerves that come out between the fourth and fifth lumbar vertebrae or between the fifth lumbar and the first sacral vertebrae.  Disc herniations, spondylolisthesis (slippage of the spine), and spinal arthritis are common causes for the nerve compression.

2.   Post surgical irritation of the nerve

In order to decompress a nerve, it has to be mobilized and freed up.  Sometimes even gentle mobilization by the surgeon and the forces required to release the pressure on a nerve by removing bone spurs, disc herniations, or other compressive soft tissues can traumatize an already injured nerve root resulting in temporary or permanent loss of that nerve function.  Fortunately, most cases are mild and most cases resolve with time when they occur post surgically.

How is it Treated?

If someone is suffering from ongoing dropped foot, then using an ankle foot arthroses (a small brace which keeps the foot upright so that it does not drop every time you take a step) can be very effective in allowing the patient to have a more normal gait pattern with minimal change of their stride phase.

When a muscle loses its nerve innervation, it tends to shrink or atrophy, because it does not have an ongoing stimulation. Electrical stimulation can be used to continue to activate the muscles in question so as to minimize any atrophy of those muscles while one awaits healing of the nerve.  Electrical stimulation is applying gentle electrical stimulation forces to the muscle causing it to contract. Nerves that are inflamed or injured heal very slowly.  In fact, they only heal at a rate of one millimeter per day.  This translates to one inch per month.  For the nerve to heal all of the way from the low back down to the foot, it can take up to three years for that nerve to heal completely, if it is severely traumatized.  The bottom line is that we hope to see recovery faster than that should a problem occur after surgery, but we will not know the final answer until we are almost three years out from the surgical event in terms of the ability to recover that function. Ultimately, the decision on using electrical stimulation depends upon the patient’s desire and the physician’s experience with the given situation.  Each case is different, but it is an option that is available to aide in select cases.

In summary, dropped foot tends to represent a loss of nerve function to muscles that cause the ankle to dorsiflex or raise off of the ground allowing the toes to clear the ground in the stride phase of gait.  This can occur as a result of degenerative process, traumatic events, and even post surgically.  With proper treatment, patients may experience complete recovery, but this can take as long as three years.  Additional treatment with physical therapy, aides, and evaluations can assist in managing this problem.

What spinal health related questions do you have for our next edition of “Ask The Expert”?

I was recently asked “how to recognize the difference between a cervical spine issue versus carpal tunnel syndrome with accompanied numbness.” As a spinal neurosurgeon, I frequently encounter a patient who has symptoms in his or her upper extremity (arm) that seemed to either extend from the shoulder down toward the fingers or extends from the fingers back up toward the shoulder.  In medicine, we use the term “differential diagnosis” to describe the possibilities which may exist to explain the symptoms.

Degeneration of the discs in the cervical spine or bone spurs associated with arthritis, can cause compression of the nerves which exit the neck and travel down the arm.  The nerve endings will have a specific distribution to the skin and musculature, which may result in pain, numbness, or weakness when those nerves are compressed. Usually, a careful physical examination will identify the source of the symptoms. For example, if neck extension (leaning backward) causes worsening of the arm pain, there is usually compression of the cervical nerve root in the spine. Similarly, if tucking the chin and tilting the head toward the shoulder opposite the pain gives some relief of symptoms, this is often associated with compression of the nerve in the foramen (spinal nerve opening).

Carpal tunnel syndrome, on the other hand, is compression of the median nerve through an area of ligaments at the wrist.  When the median nerve is compressed, many times patients will complain of pain, numbness, and weakness affecting the thumb, index, and middle finger. Carpal tunnel syndrome is often activity-dependent, meaning that when the hands are used more frequently such as typing or grasping a screwdriver, the symptoms can be exacerbated.  Many patients will complain of numbness when they sleep, often from curling the wrist and hand under a pillow.

The difference between cervical radiculopathy and carpal tunnel syndrome is often made clinically by using not only a careful neurologic examination but also by provocative tests, which can often cause irritation of a cervical nerve root in the neck or by tapping the overlying carpal tunnel itself, causing reproduction of symptoms into the hand.  If a careful physical examination cannot disclose the cause of the symptoms, whether it be the neck or the carpal tunnel, then many times an EMG (electromyogram) test may be utilized.  The EMG test is utilized to determine the contribution of nerves to the symptoms.  The nerve endings may be compressed in the neck or may be compressed as they cross either the elbow or the wrist.

In any case, the differential diagnosis of cervical radiculopathy versus carpal tunnel syndrome can often be difficult for both the provider and the patient.  Usually a combination of clinical acumen, electromyographic testing, and physical therapy is helpful in defining the problem in most cases.

What spine related question do you have for our next edition of “Ask The Expert”?

How does a low back muscle strain occur and how is it treated?

When force exceeds a muscle’s threshold for strength production, injury can occur. Regarding the lumbar spine musculature, lifting from a position of flexion and rotation is the most common mechanism of injury, often creating forces greater than eight times a person’s body weight. The pathogenesis of overloaded muscles can lead to involuntary shortening, loss of oxygen supply, loss of nutrient supply, and trigger point formations. When muscle is strained from severe trauma, overuse, or mechanical overload, there is a disruption of the muscle’s basic elements myosin and actin. In a normal muscle, these two proteins slide on each other as the muscle contracts. When injured, these proteins remain stuck on one another and often lead to trigger points or shortened muscle fibers. Treatment for muscle strain begins with control of swelling, pain, and edema. The first three days of treatment following injury should consist of ice, compression, and avoidance of activities that may create more injuries. Day three up until six weeks, should consist of gentle range of motion, soft tissue mobilization via dry needling or cross friction massage, and strengthening within the patient’s tolerance.

How long do muscle strains usually take to heal?

Grade I muscle strains mean that only 25% of the muscle fibers were injured. These types of strains present with pain when stretched, but no strength loss during resisted testing. The strains heal between three days and two weeks. Grade II tears infer that 50% of the muscle fibers are involved and normally take four to six weeks to fully heal. Grade II tears are diagnosed by pain upon stretch and pain and weakness against resistance. Grade III muscle tears usually require surgical intervention and may require from 12 weeks to one year of rehabilitation to fully heal. These tears are diagnosed when 75% to 100% of the muscle fibers are injured, there is a complete loss of strength when manually tested, and the response to stretch or contraction is painless since the muscle’s nerve supply was also disrupted during the injury.

What are myofascial trigger points and how are they treated?

Myofascial trigger points are defined as taut, hyper-irritable bands within a skeletal muscle that are painful with palpation. Myofascial trigger points often refer pain to other regions surrounding the tissue. They also may twitch or involuntarily contract when palpated. Research has identified an increased metabolic demand within tissues containing trigger points. In my opinion the most effective method of treating myofascial trigger points is through dry needling. Dry needling releases shortened muscles, produces local inflammation necessary for healing, and removes chemical elements responsible for pain production.

Richard Banton, PT, DPT, OCS, CMPT, ATC serves as a a co-clinic director at Virginia Therapy and Fitness Center. To read his complete bio, click here.

Question {Lisa B.}: Can repeated spinal injections over time cause further disc degeneration?

Answer {Dr. Nguyen}: Lisa, thank you for your question. There is no data at this time that points to any correlation between repeated spinal injections leading to further disc degeneration.  Most of the time, there is a limit on the number of injections over a period of time to limit any possible adverse effects from accumulation of these injectable steroids.  It would be difficult to study as most of the patients receiving these spinal injections have some sort of advanced degenerative disc degeneration leading to their complaints of pain.

* Please not: the content of this post is provided for general informational purposes only. It is not intended as, nor should it be considered a substitute for, professional medical advice. This information should not be used for diagnosing or treating any medical or health condition. If you have or suspect you have a medical problem, promptly contact your healthcare provider.

When every joint in your body feels swollen and throbbing with pain, the last thing you want to do is move them. Though you may not feel like moving, it can be one of the best things you can do to manage your condition. Pain and fatigue is a daily reminder when living with Rheumatoid Arthritis (RA). It is important to set goals to be active daily, which will leave you feeling more energized and in less pain. If you still need motivation, enlist a friend to join you for a workout or even just a walk around the block.

Here are some helpful tips to manage your condition at home:

• Get your morning started with a hot shower. Moist heat will relax your muscles and boost blood flow.
• Try aquatic exercises which can also help to alleviate some pain and stiffness. Water’s buoyancy relieves pressure to the joints, making movement easier and less painful.
• If you are in too much pain in one area of your body, go ahead and work on another area, to keep moving is key to decrease the progression of RA.
• Engage in knee exercises. If your fingers and wrists are causing too much pain, try some simple knee exercises.

If your at-home therapy isn’t easing the pain a physical therapist can help. Here’s how!

1. A physical therapist will be able to tailor a program based on your RA symptoms and disease progression. This will allow for a specific exercise regimen that will help target your specific problems associated with RA.
2. Physical therapy can help patients cope with the pain and disability that arthritis causes. Because there is not a cure for arthritis, the focus of treatment is on pain management to increase function. Daily physical therapy exercises can help strengthen bone and muscles around your joints, which helps decrease the degenerative progression of RA.
3. A physical therapist will be able to provide joint protection techniques, heat and cold treatments, splints or orthotic devices to support and align joints for patients with RA that may be very helpful in decreasing symptoms and increasing function.
4. Physical therapists will help develop a patient specific at home exercise program. It is important to work with a physical therapist for correct form on repeated exercises so that patients avoid further injury or pain.

Where did you turn when the pain from your RA was too much to manage yourself? What tactics worked best for you?

Answer [Dr. Christopher Good]: It is absolutely true that degenerative disc disease and spine trouble are based on genetics, meaning that they tend to run in the family. Genetics may increase your chances of having spine troubles, however, there are actions that you can take to prevent or decrease these odds.

First and foremost, we know that smoking causes severe rapid degeneration of the discs in the back and for people who have spine problems in their family, avoiding smoking and all nicotine products can greatly reduce the chances that you will need future surgery.

In addition to putting extra strain on your neck and back, extra weight increases stress on other organs and can lead to medical conditions such as heart disease and diabetes. Losing weight can help to protect your spine, and at the same time benefit your overall health and well-being.

Shedding those extra pounds can decrease the amount of stress that is put on a herniated or degenerative disc and may protect it for years to come. Imagine a car that is packed full of people.  When all of the people are in the car, the additional weight causes the tires to flatten and the bottom of the car is closer to the ground.  When everyone gets out of the car, the bulging of the tires goes back to normal again. This is one way to visualize the improvement of bulging degenerative discs in people who are able to lose weight.

Weight loss is based on a nutritious, healthy diet as well as healthy lifestyle and exercise routine.  For people with spinal troubles, it is important to focus on low impact aerobic fitness and core strengthening in order to prevent an injury while you are getting in shape.

Talk to your doctor before starting a new exercise program, and stop any exercise immediately if it causes your pain to get worse or leads to new problems.

There is a misconception that all spine institute’s were created equal.

Often times there is confusion in choosing where to receive treatment. This is where the all-under-one-roof spine institute is most beneficial to the patient. These spine institutes comprise physicians of multi disciplines (spinal specialists, pain management physicians, and physical therapists) working together in one location to provide convenience of specialty care. When physicians of multiple specialties work side by side it results in the most rapid recovery getting the patient back to their lifestyle more quickly. These spinal specialists are double board certified in spinal surgery as well as their own primary specialty of orthopaedic surgery or neurosurgery and lead practices that are dedicated 100% to spinal health care. They work along side pain management doctors of physiatry and/or anesthesia backgrounds to optimize patient care and safety. It is important that they also have expert in-house rehabilitation (physical therapy) focused on the spine and pain resolution. When all of these treatment capabilities are combined under one roof by doctors working on the same team for the benefit of the patient, outstanding results can be obtained.

However, the confusion for the consumer sets in when hospital and university systems market themselves as “spine institutes”. These fabricated models present themselves as “store fronts” comprising various providers working out of their independent institutions with separate sets of goals. Furthermore, many of the physicians who are in these “spine institutes” are not board certified in spinal surgery or in their sub specialties and are merely general neurosurgeons or orthopaedic doctors that perform spine surgery part-time. This poses as a disservice to the patient as they end up traveling from facility to facility (while in pain) with separate medical records which may create disjointed diagnoses and treatment. All of this lengthens the patient treatment process and increases the chance for duplication and the risk for complications. Often times this creates a misconception for the patient that they are dealing with an expert because of the marketing campaign by the hospital system and/or university. This is can pose as a risk to the patient.

Make sure when you experience neck or back symptoms to be diligent in seeking the most comprehensive care from qualified specialists who are solely dedicated to the spine. Where did you turn when you experienced the first symptoms of neck or back pain?

It has become a common perception by patients that minimally invasive surgery means performing surgery through small tubes, or by using microscopes, or using lasers or robots. These tubes and other retractors, microscopes, lasers, and robots are merely tools used to do surgery. They are not, by themselves, MIS. Please understand, just because a provider uses these tools does not make the surgery minimally invasive.

MIS  is performed with the least tissue manipulation necessary, while still accomplishing the goals of the surgery. With my patients I look to reduce trauma to the body and allow it to heal as fast as possible by carefully considering the most efficient and effective surgery for each patient.

For example, many years ago, knee surgeries required big incisions. Now many knee surgeries can be performed with small incisions and arthroscopes, which can actually show the pathology more precisely and with less collateral damage (and a shorter healing time). The same thing has been discovered with advances in gallbladder surgery. Now, most gallbladder surgery is done via endoscopic surgery.

Knowing the anatomy of the body is essential. Knowing where the blood supply is, protecting the nerves, and keeping muscles intact when possible, are all essential to MIS.  If spaces in between muscles and tissues can be separated as opposed to being cut, then there is less healing required.  If smaller incisions can be made, while still seeing what needs to be seen, and doing what needs to be done, then the body can heal faster.

The Society of Minimally Invasive Spine Surgery (SMISS) and other organizations to which I belong continue to advance the field of MIS. In our societies, we continue to teach the principles of MIS, as well as teach the actual techniques, to surgeons around the world.

To perform MIS, we use various tools–tubes, x-ray/flouroscopy, lasers, robots, endoscopes, microscopes, and cameras. But the principles of surgery are the same as traditional procedures. The body heals the same way as before, but with more direct approaches, there is less to heal, so we can get the job done, and get the patient up and moving faster, and with less discomfort. As an active participant in clinical trials and as a pioneer of artificial disc and other minimally-invasive procedure, I have found that the complexity of the case doesn’t necessarily mean that MISS is ruled out.

As spinal specialists, at the Virginia Spine Institute, it is part of our DNA to constantly seek better ways to improve our patients’ lives.

What is your perception of Minimally Invasive Surgery?