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.

You don’t have to be a runner to participate in the Spinal Research Foundation’s upcoming We’ve Got Your Back Race For Spinal Health {May 18^th}! Walking is an excellent form of exercise; whether you are just starting to exercise, recovering from an injury or are just looking to get outside and get moving; read on for tips on how walking can improve your life and what you need to get started.

Physical activity in general helps to control your weight and improve overall health. Adults need at least two and a half hours of physical activity a week at a moderate level. Fast paced walking would meet those requirements. According to the CDC, adults who walk for transportation, fun or exercise went up 6% from 2005.

Benefits Of Walking:

• Can help lower LDL cholesterol (bad cholesterol)
• Lowers blood pressure
• Reduces risk or manages type 2 diabetes
• Manage weight
• Maintains fitness and strength
• Improves mood

Walking is a great, low impact exercise that is not as strenuous as other forms of physical activities. However, if you have cardiovascular disease or high blood pressure, it is important to consult with your physician before beginning a new exercise program.

To Get Started:

• The only special gear needed is a good pair of shoes, look for a pair with a flexible sole and proper arch support, as well as fit
• Warm up your muscles by walking in place
• Stretch out your muscles (calves, quads, hamstrings, and sides)
• Cool down, end your walk with about five minutes of a much slower paced walk, then finish with stretching

To make the most out of your walking sessions, pace and distance will surely give gauge your results. If you are a beginner walker, you should gradually increase your time and pace. The speed at which you walk should be as brisk as your condition permits. Be sure to listen to your body, if you feel faint, dizzy or any other symptoms that leave you uncomfortable; slow down or stop. If symptoms persist contact your physician.

Where is your favorite place to go walking?

Causes
Leg length discrepancies can be caused by poor alignment of the pelvis or simply because one leg is structurally longer than the other.  Regardless of the reason, your body wants to be symmetrical and will do its best to compensate for the length difference.  The greater the leg length difference, the earlier the symptoms will present themselves to the patient.   Specific diagnoses that coincide with leg length discrepancy include: scoliosis, lumbar herniated discs, sacroiliitis, pelvic obiliquity, greater trochanteric bursitis, hip arthritis, piriformis syndrome, patellofemoral syndrome and foot pronation.  Other potential causes could be due to an injury (such as a fracture), bone disease, bone tumors, congenital problems (present at birth) or from a neuromuscular problem.

Symptoms
•    An obvious observance of one leg being longer than the other
•    Affected posture
•    Problems with gait (manner of walking)
•    Pain in the lower back, hip, ankle or knee

Classifications
Leg length discrepancies can be classified as a structural leg length discrepancy or a functional leg length discrepancy.  A structural leg length discrepancy is a hereditary circumstance that one leg is simply longer than the other leg.  This is determined if the patient’s pelvis and sacroiliac joints are symmetrical and the leg length is simply due to one leg truly being longer than the other.  The best way to determine if a structural leg length discrepancy is present is with an anterior-posterior x-ray of the pelvis.  A clinical alternative is using a tape measure to measure the length of the leg from the hip to the ankle.
Functional leg length discrepancy is diagnosed when there is a torsion or pelvic rotation/obliquity, commonly a sacroiliac joint dysfunction, which causes one leg to function as though it is longer or shorter than the other.  In order to determine if a true structural discrepancy exists, the physical therapist must treat the pelvis and return it to a neutral position before measuring for the leg length discrepancy.  Once the pelvis is symmetrical it is determined if the leg length discrepancy remains or if it goes away, if it goes away it is classified as functional.  If it remains and has a measurable difference, it is a structural leg length discrepancy.

Treatment
Structural leg length discrepancy can be treated with a heel lift in the shorter leg’s shoe, if the leg length is greater than 5 mm.  The use and size of the heel lift is determined by a physical therapist based on how much lift is needed to restore proper lumbopelvic biomechanics. In certain cases, surgical intervention may be needed to either shorten or lengthen the limb. An important component to any surgical procedure to correct leg length discrepancies is physical therapy. Physical therapy  helps to stretch muscles and maintain joint flexibilty, which is essential in the healing process.
For a functional leg length discrepancy no heel lift is required, but proper manual therapy techniques and specific therapeutic exercise is needed to treat and normalize pelvic and lower extremity compensations.  The number of treatments needed to hold the pelvis in a symmetrical position is different for each patient based on their presentation and biomechanical dysfunctions in their lower back, pelvis, hip, knee, and foot/ankle.
If you have pain in your lower back or lower extremity and possibly a length discrepancy; the two symptoms could be related.  A good place to start would be a physical therapy evaluation to determine whether you have a leg length discrepancy and if it could be contributing to your lower back pain, hip pain, knee pain, or leg pain.

An estimated nine out of ten people will experience back pain at some point in their lives. Though back or neck pain becomes more common as we age, it affects all ages and does not discriminate between male or female, both sexes are equally susceptible.

What is Idiopathic Scoliosis?

Idiopathic scoliosis is a common pediatric spinal deformity and up to 80% of cases occur in children. Scoliosis is an abnormal curvature of the spine, either right or left. The abnormal curve is similar to an S or a C shape instead of a straight line of vertebrae. Idiopathic scoliosis at this time has no known causation and is classified based on the age of onset (adolescent or adult) the other form is congenital scoliosis which is present at birth.

Research & Genetics

Research studies have worked to identify potential factors involved in the causation of scoliosis in order to enable physicians to more accurately predict the prognosis for patients with scoliosis and to offer more effective treatments.

The involvement of genetic factors in the development of adolescent idiopathic scoliosis has become widely accepted in the medical community. A number of population studies have documented that scoliosis runs within families and that there is a higher prevalence of scoliosis among relatives of patients with the condition than within the general population. Armed with this knowledge, it would be important to make your primary care physician aware of your child’s familial history. In addition, you can be more tuned into the developmental changes in your child’s back as he or she continues to grow.

Genetic Prognostic Testing

There is a DNA test that can indicate the likelihood of progression into a severe curve for children diagnosed with idiopathic scoliosis. The test is named the ScoliScore, which is appropriate for children nine to thirteen years of age with a mild to moderate curve. The simple test is performed by analyzing the patient’s saliva. The test assigns a number from 1-200 which indicates the likelihood for the curve progressing. The assigned number is based upon the child’s DNA and their current Cobb angle (named after American orthopedic surgeon, John Robert Cobb, this measures the angle of the curve on an x-ray). This test is revolutionary in that it helps take some worry out of the equation and allows the child and the parents the ability to have a clearer picture of their child’s future spinal health.

Many factors may be related to the development of idiopathic scoliosis and no single cause has been identified at this time. Adolescent idiopathic scoliosis appears to be highly dependent on genetics as well as to the unique biomechanics of the spine. A number of recent breakthroughs in genetic testing will lead to improved diagnosis and treatments for patients with adolescent idiopathic scoliosis.

For the full article, originally published in the SRF Journal, click here.

What are you doing May 18th?

The Virginia Spine Institute is proud to team up with the Spinal Research Foundation (a national 501(c)(3) non-profit organization) to host the Sixth Annual, “We’ve Got Your Back” 5K race and 1 mile fun run/walk for spinal health. All proceeds from the race directly benefit the Spinal Research Foundation’s mission to improve spinal health care through research, education, and patient advocacy. Sign up for the 2013 event to make this the largest race in the nation for spinal health care — and don’t forget to join your doctor’s team!

WHY JOIN A TEAM: Together everyone achieves more! Connect with your favorite medical team at this fun-filled community event. Team up with your doctors with the goal of improving the future of spinal health care. Invite your friends and family to join your doctor’s team as well.

HOW TO REGISTER AS A MEMBER OF A TEAM: It’s easy! When prompted to enter participant information on page two of the online registration, select your doctor’s team name from the drop down menu. Regardless of whether you are entering the 5K run or 1 mile walk, you are eligible for any of the teams.

For additional event information and to see highlights from last year’s race; visit us online.
If you have any questions please email us race@spinerf.org.

What is the gluteus medius?

The gluteus medius is one of three gluteal muscles that make up your buttocks and is located on the outside of your hip and pelvis. To find it, feel for your greater trochanter. The trochanter is the bony protuberance on the outside of you hip. Run your finger straight up towards your pelvis about an inch or two. To confirm that you found it, start walking. When you are standing on one leg, you should really feel that muscle tighten up. When you step off that leg, it turns off. Did you find it?

How does it function?

Functionally, the gluteus medius stabilizes your pelvis and hip as you walk and run. It helps reduce the likelihood of ACL tears by preventing the knee from buckling inward.  Additionally, it controls your foot and ankle by rotating your entire lower extremity to allow for supination and pronation. To see that in action, stand in your bare feet with your feet flat and hip width apart. Then rotate your body to the right and to the left. Watch the arches in your feet. You should see your arches alternately flatten and rise up.

Because the average person takes between 5,000 and 10,000 steps a day, the gluteus medius MUST be able to handle the work load. Below are two exercises to focus on to strengthening the gluteus medius.

1. Side-lying hip abduction-Lying on your side with head resting on bottom arm, legs straight, and the top leg slightly behind the bottom one. Slowly lift your top leg skyward, keeping your toes pointed straight ahead. Slowly return to start position.  Start with 2 sets of 10 repetitions.

Progress as you can to 3 sets of 15-25 repetitions. Add some ankle weights if it gets too easy.

1. Single limb balance-with or without shoes try to balance on one foot for as long as you can. Experts can last up to 2 minutes without losing their balance. When that gets easy, try turning your head slowly from right to left. Or play catch with a buddy as you balance. First on to lose their balance…loses!

What questions do you have for our Athletic Trainer, Jason Arnett?

Three Yoga Poses To Ease Neck & Back Pain:

Wide- Legged Forward Bend

• Stand with your feet about three to four feet apart, turn heels out slightly
• Clasp your hands behind your back, pressing your palms together
• Lean forward, slowly bending at your hips, bring the crown of your head and hands towards the floor (go as far as you can without discomfort)
• Stay in the position (if you can) for five deep breaths.
• Gently press into your feet and use your quads and inhale as you stand up

Cow & Cat Stretch

• Start on your hands and knees, hands beneath your shoulders and knees under your hips
• Keep your spine neutral, with your back flat, abs engaged, looking at the floor
• Inhale, and lift your sitting bones and chest towards the ceiling, while letting your belly “sink” towards the floor, lift you head and look ahead
• Upon exhale,  round your spine towards the ceiling {you can imagine your are pulling your belly button towards your spine}
• Tuck your chin towards your chest and let your neck relax
• Continue repeating the cow and cat pose about 10 times { or less if you have too}

Child’s Pose

• Kneel on the floor, sit on your heels with knees hip width distance apart
• While exhaling, lie your torso on your thighs and extend your arms out in front of you
• Hold for about 30 seconds to one minute

What Yoga pose gives you the most relief?

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”?

True Story:

Over a period of six months, I saw numerous physicians both orthopedic and neurosurgeons discussing my situation. I used to work in medical research and grant funding, so for me (and my back), this was a research project.

Along with my many back diagnoses and because of my scoliosis, I was referred to Dr. Good. He was considerate, attentive, intelligent and highly experienced. I had been having lower back pain that radiated into my legs. After diagnostic imaging results came back; I was diagnosed with spinal stenosis.  I was a candidate for back surgery.

I couldn’t be more pleased with the results of my surgery. I am proud to say at my six month mark I am almost 100% recovered. I did as I was guided and worked really hard at physically recovering. I have always exercised and now I put my best foot forward (and back) to the test. Today I am swimming my normal 25-30 laps, plus water aerobics and other physical workouts. As a minor note, I am 73 years old. They say healing takes longer after age 60. I am proud to say, I pushed the limits and moved relatively quickly through my milestones.

Thank you for the wonderful care and giving me back my life. I am so thankful and blessed to have made this fantastic recovery with the help from all of your staff.

Proper posture is critical in reducing neck, shoulder and low back pain. If you sit at a desk most of the day, chances are you have experienced some sort of pain in your neck and shoulders.  This common pain is a result of poor posture and gravity pulling you down all day long. Our society is becoming increasingly more  sedentary, and our bodies are paying the price.  For example, you commute to work, you sit at your desk for a good portion of the day, you then get back into your car to go home,  you sit down for dinner, and then sit some more and watch television. Sound familiar? The following tips can help you inside and outside of the workplace.

There are a few things you can do to help to ease or potentially “cure” your ailments.

• Pay attention to your posture. To help set yourself up for success in maintaining better posture all day long, you need to adjust your workstation for optimal ergonomic productivity. Click here to find out how to position your chair, monitor, mouse and more! Get double use out of these tips and apply them to your office at home!

• Next, get up out of that seated position at least once an hour. Get up to get a drink of water, use the restroom, fire someone…anything. Just get up!

• Now it’s time to find a corner and stretch. As your shoulders round, the muscles in the front of the chest (pectoralis major) become very tight.  Stretching will help to straighten out your posture and relieve any tightness and potential pain.

Here’s how:

Hold a comfortable stretch in the corner for about 20 seconds. Relax. Do it two more times for a total of three. Stretching can be done several times a day. Remember, being comfortable is the key. Don’t force the stretch.  You should feel the  stretch in your chest and maybe in the front of your shoulder, nowhere else.

Often times you might be too engrossed in your work to “remember” to get up. Set a reminder in your calendar or on your phone for every hour to  get up and move around, in addition you can use this time to do some stretching, your body will thank you!

What do you do at work or home to remind yourself to get up and stretch?

Jason Arnett, MS, ATC, PES